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MANUALS 

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Students   of  Medicine. 


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A 


Manual  of  Surgeri^ 

In   Treatises  by   Various  Authors. 

IX    THREE    YOLrMES. 
EDITED    BY 

FREDERICK   TREVES,    F.R.C.S., 

-UK6E0>'   TO,   AND   LECTUREE  OX   AXATOilT   AT,    THE   LONDON    HOSPITAL 
HUXTEKIAN   PBOFESSOE   AT   THE   ROYAL    COLLEGE    OF 
SURGEONS   OF   ENGLAND. 

Foluiuf  IIH. 

THE  ORGANS  OF  LOCOMOTION  AND  OF  SPECIAL 
SENSE  —THE  RESPIRATORY  PASSAGES  —  THE 
HEAD  — THE    SPINE. 


7 


ILLUSTRATED    WITH   124    ENGRAVINGS. 


FHILAIjLLFHIA  . 

LEA      BROTHERS     &     CO 

1892. 


2. 


\i 


LIST    OF    AUTHOES. 


WILLIAM  ANDERSON,  ESQ.,  F.R.C.S. ;  Assistant .SurgeoD  to,  and  Lecturer  on 
Anatomy  at,  St.  Thomas's  Hospital. 
Animal  Poisons. 

W.  MITCHELL  BANKS,  ESQ.,  F.U.CS. :  Professor  of  Anatomy,  Uniyersity  Col- 
lege, Liverpool  ;  Surfr<0!i  to  the  Liverpool  Royal  luflnuary. 
Diseases  of  the  Breast. 

H.  TRENTHAM  BUTLIN,  ESQ.,  F.R.C.S. ;  Assistant  Surgeon  to  St.  Bartholo- 
mew's Hospital. 
Tumours. 

JAMES  CANTLTE.  ESQ.,  M.A.,  M.B.,  F.R.C.S. ;  Assistant  Surgeon  to  Charing 
Cross  Hospital. 

GuiL-fihot  Wounds.  Injuries  and  Diseases  of  the  Testis,  Scrotum, 
and  Penis. 

JOHN  CHIENE,  Esq.,  MD.,  P.R.C.S.B.,  F.R.S.E.;  Professor  of  Sursrery,  Univer- 
sity of  Eilinburgh  ;  Surgeon  to  the  Royal  Infirmary,  Edinburgh. 
The  Process  of  Repair.     Wounds. 

ANTHONY   H.  CORLEY,  ESQ.,   M.D.,  F.R.C.S.T.  ;  Lecturer    on    Surgery,    Car- 
michael  College,  Dublin ;  Examiner  in  Surgery,  Royal  University,  Ireland  ; 
Surgeon  to  the  Richmond  Hospital. 
Injuries  of  the  Head. 

HARRISON  CRIPPS,  ESQ.,  F.R.C.S.;  Assistant  Surgeon  to  St.  Bartholomew's 
Hospital. 

Diseases  of  the  Rect  \im. 

JOHN  CROFT,  Esq.,  F.R.C.S. ;  Surgeon  to.  and  Lecturer  on  Clinical  Surgery  at, 
St,  Thomas's  Hospital ;  Examiner  in  Surgery,  Royal  College  of  Surgeons  of 
England. 

Injuries  and  Diseases  of  the  (Esophagus. 
JOHN  DUNCAN,  Esq..  M.D.,  LL.D.,  F.R.C.S.E.,  F.R.S.E.  ;  Lecturer  on  Surgery, 
Edinburgh  School  of  Medicine  ;  Surgeon  to  the  Royal  Infirmary,  Edinburgh. 
Gangrene.    Erusipelas. 
FREDERIC  S.  EVE,  Esq.,  F.R.C.S. ;  Assistant  i=!urgeon  to  the  London  Hospital ; 
Pathological  Curator,  Royal  College  of  Suriroons,  England. 

Burns  and  Scalds.  Scrofula  and  Tuberculosis.  Rid'cts.  Hectic 
or  Suppurative  Fever.  Traumatic  Fever.  Traumatic 
Delirium. 

GEORGE  P.  FIELD,  ESQ.,  M.R.C.S. ;  Aural  Surgeon  to  St.  Mary's  HospitaL 
Diseases  of  the  Ear. 

A.  PEARCE  GOULD,  ESQ.,  M.S.  Lond.,  F.R.C.S. ;  Assistant  Surgeon  to  the  Mid- 
dlesex Hospital ;  Suri-'eon  to  the  Royal  Hospital  for  Diseases  of  the  Clust. 
Injuries  of  Blood-Vc^sels.    yluewrisin.  The  Surgery  of  the-  Chest, 
Diseases  of  Blood-Vessels.  . 

J.  GREIG  SMITH,  ESQ.,  M.A.,  M.B.,  F.R.S.E. ;  Surgeon  to  the  Bristol  Royal  In- 
firmary. 

Diseases  of  the  Bones. 

R.  MARCUS  GUNX,  Esq.,  M.A.,  M.B.,  F.R.C.S.  ;  Assistant  Surgeon  to  the  Royal 
London  Oiilitbalraic  Hospital,  Moorflelds. 
Ki'sedses  of  the  Eye. 

VICTOR  HORSLEY,  Esq..  B.S.  Lond.,  P.R.S..  F.R.C.S.;  Assistant  Surgeon  to  Uni- 
vcreity  College  Hospital ;  Pi'ofessor  Superintendent  of  the  Brown  Institute. 
Injunes  and  Diseases  ofiiie  Neck, 

/OKATHAN  HUTCHINSON,  Esq.,  F.K.a. ;  Consulting  Surgeon  to  the  London 
Hospital  ;  Examiner  in  Surgery,  RoyaJ  College  of  Surgeons.  England. 
Syphilis. 


n  List  of  Authors. 

JONATHAN  HUTCHINSON,  Esq.,  Jcy..  F.R.C.S. ;  Surgical   Reyistiar  to   the 
London  Hospital. 
Teianxxi, 

FURNEAUX  JORDAN,  Esq.,  F.R.C.S. ;  Professor  of  Surgery,  Queen's  College, 
Birmingbam  ;  Surgeon  to  the  Queen's  Hospital. 
S/iocfc. 

SIR   -SVTLLIAil    MACCORMAC.     M.A.,    D.Sc,    F.R.C.S.;    Surgeon     to,    and 
Lecturer  on  Surgery  at.'St.  Thomas's  Hospital ;  Examiner  in  Snrgery,  Uni- 
versity of  London. 
Hernia, 

HOWARD  MARSH,  ESQ.,  F.R.C.S. :  Assistant  Surgeon  to,  and  Lecturer  on  Ana- 
tomy at,  St.  BnrtliolonieWs  Hospital ;  Surgeon  to  the  Hospital  for  Sick 
Children,  Great  Orraond  Street. 
I)i'oeases  0/  Joints. 
JO.SEPH  MILLS.  Esq.,  M.R.C.S.  ;  Anesthetist  to  St.  Bartholomew's  Hospital. 
An<JEsthesia. 

HENRY  MORRIS,  Esq.,  M.A.,  M.B.  Lond.,  F.R.C.S. ;  Surgeon  to,  and  Lecturer 
on  Surgerj-  at,  the  Middlesex  Hospital. 

Injuries  and  Diseases  of  the  Abdomen.  Injuries  and  Surgical 
Diseases  of  the  Kidney. 

MALCOLM  MORRIS,  E.sQ.,  F.R.CS.E. ;  Surgeon  to  the  Skin  Department,  St. 
Mary's  Hospital. 

Surgical  Affections  of  the  Skin.     Scurvy. 

C.  MANSELL  MOULLIN,  Esq..  M.A.,  M-D.  Oxon.,  F.R.C.S. ;  Assistant  Surgeon  to 
the  London  Hospital ;  Fellow  of  Pembroke  College,  Oxford. 

Ulcers.  Pycemia  and  SepticcBiaia.  Injuries  and  Diseases  of 
Liimphatics.     Diseases  of  the  Urinary  Organs. 

HERBERT  W.  PAGE,  ESQ.,  M.A.,  M.B. :  Cantab.,  F.R.C.S.;  Surgeon  to,  and 
Lecturer  on  Surgery  at,  St.  Mary's  Hospital. 

Injuries  and  Diseases  of  Nervea,  Injuries  of  the  Spine. 
Diseases  of  the  Spine. 

AUGUSTUS  .T.  PEPPER,  Esq.,  M.S.  Lond.,  F.R.C.S. ;  Surgeon  to  St.  Mary's  Hos- 
pital ;  Exaiuiner  in  Forensic  Medicine,  University  of  Loudon. 

Diseases  of  the  Jaws.     Gonorrhoea.    Abscess.     Contusions. 

T.  PICKERING  PICK.  ESQ..  F.R.C.S.  ;  Surgeon  to.  and  Lecturer  on  Surgery  at, 
St.  George's  Hospital ;  Examiner  in  Surgery,  Royal  College  of  Surgeons  or 
England. 

Injuries  of  Joints. 

HENRY  SEWILL,  Esq.,  M.R.C.S.,  L.D.S. 
Dental  Surgery. 

FREDERICK  SOUTHAM,  Esq.,  M.A.,M.B.  Oxon.,  F.R.C.S. ;  Assistant  Surgeon  to 
the  Manchester  Royal  Infirmary  ;  Assistant  Lecturer  on  Surgery  at  Owen's 
College. 

Fractures. 

8IR  WILLIAM  STOKES,  M.D.,  P.R.C.8.I.;  Professor  of  Surgery,  R.GS  ,  Ireland; 
Examiner  in  Surgery,  Queen's  University,  Ireland;  Surgeon  to  the  Rich- 
mond Hospital. 

General  Principles  of  Operative  Surgery 

FREDERICK  TREVK.S.  Esq.,  F.R.C.S.;  Surgeon  to,  and  Lecturer  on  Anatomy 
at,  the  London  Hosiiital. 

Hysttria.      Injuries  and  Dtsea.«es  of  the   Female  Generative 
OrganSt    Diseases  of  the  Head.    Hcemophilia. 
W.  J  WALSHAM,  Esq.,  M.B.,  F.R.C.S. ;  .Assistant  Surgeon  to  St.  Bartholomew's 
Hospital ;  Surgeon  to  the  Orthopaedic  Department,  St.  Bartholomew's  Hos- 
pital. 

Orthopcedic  Surgery.  Injuries  and  Diseases  of  Muscles,  Ten- 
don.'f,  Fascice,  and  Bursce,  Diseases  of  the  Nose  and  .Nasal 
Cavities. 

WALTER  WHITEHEAD,  ESQ.,  F.R.CS.E.,  F.R.S.E.  ;Surgeonto  the  Manchester 
Royal  Intlrniary  ;  Lecturer  on  Clinical  Surgery,  Owen's  C(. liege. 
A£ccti0'is  of  the  Mo^uth,  Palate,  Tongur,  and  Toiibil. 


CONTENTS:    VOLUME   11. 


PAUE 

I.  FRACTURES 1 

By  Frederick  A.  SouTham,  M.A.,  MB.  Oxon.,  F.R.C.S. ; 
Assistant  Lecturer  on  Surgery  at  Owen's  College; 
Assistant  Surgeon  to  the  Manchester  Royal  Inflrnury. 

II.  DISEASES  OF  THE  BOXES 93 

By  J.  Greig  Smith,  M.A.,  :M.B..  F.R.S.E.  ;  Surgeon  to 
the  Bristol  Royal  Infirmary. 

III.  INJURIES  OF  JOINTS 119 

By  T.  Pickering  Pick,  F.R.C.S.  ;  Surgeon  to,  and  Lec- 
turer on  Surgery  at,  St.  George's  Hospital;  Examiner 
in  Surgery,  Royal  College  of  Surgeons  of  England. 

IV.  DISEASES  OF  JOINTS 210 

By  Howard  Marsh,  F.R.C.S. ;  Assistant  Surgeon  to,  and 
Lecturer  on  Anatomy  at,  St.  Bartholomew's  Hospital ; 
Surgeon  to  the  Hospital  for  Sick  Children,  Great 
Ormond  Street. 

V.  INJURIES   ANT)    DISEASES    OF    MUSCLES,    TEN- 

DONS, FASCIA,  AND  BURS^ 301 

By  W.  J.  Walsham,  M.B.,  F.R.C.S.  ;  Assistant  Surgeon 
to  St.  Bartholomew's  Hospital ;  Surgeon  to  the  Ortho- 
paedic Department,  St.  Bartholomew's  Hospital. 

VI.  ORTHOPEDIC  SURGERY 324 

By  W.  J.  Walsham,  MB.,  F.R.C.S. ;  Assistant  Surgeon 
to  St.  Bartholomew's  Hospital  ;  Surgeon  to  the  Ortho- 
psedic  Department,  St.  Bartholomew's  Hospital. 

"VII.    DISEASES  OF  THE  HEAD 363 

By  Frederick  Treves.  F.R.C.S. ;  Surgeon  to,  and  Lec- 
turer on  Anatomy  at,  the  London  HospitaL 


viii  Manual  of  Surgery. 

PAOE 

VIII.  INJURIES  OF  THE  HEAD 380 

By  Anthoxy  H.  Corley,  M.D.,  F.R.C.S.I.  ;  Lecturer  on 
Surgery,  Carmichael  College,  Dublin  ;  Examiner  in 
Surgery,  Royal  University,  Ireland ;  Surgeon  to  the 
Richmond  Hospital. 

IX.  DISEASES  OF  THE  SPINE 427 

By  Herbert  W.  Page,  M.A.,  M.B.  Cantab.,  F.R.CS.  ; 

Surgeon  to,  and  Lecturer  on  Surgery  at,  St.  Mary's 
Hospital. 

X.  INJURIES  OF  THE  SPINE 447 

By  Herbert  W.  Page,  M.A.,  M.B.  Cantab.,  F.R.CS.  ; 
Surgeon  to,  and  Lecturer  on  Surgery  at,  St.  Mary's 
Hospital. 

XL    INJURIES  AND  DISEASES  OF  THE  NECK       .       .472 
By  Victor  Horsley,  B.S.  Lond.,  F.R.S.,  F.R.CS  •  Assist 
Surgeon  to  University  College   Hospital;   Professor 
Superintendent  of  the  Brown  Institute. 

XIL    DISEASES   OF   TJ^:   NOSE   AND    NASAL    CAVI- 

^'^^^S 507 

Bv  W.  J.  Walsham,  M.B.,  F.R.CS.  ;  Assistant  Surgeon 
to  St.  Bartholomew's  Hospital ;  Sui-geon  to  the  Ortho- 
paedic Department,  St.  Bartholomew's  Hospital. 

Xin.    DISEASES  OF  THE  EAR 534 

By  George  P.  Field,  IVr.R.CS. ;    Aural  Surgeon  to  St. 
Mary's  Hospital. 

XIV.    DISEASES  OF  THE  EYE 54„ 

By  R.  Marcus  Glxn,  M.A.,  M.B.,  F.R.CS. ;  Assistant 
b'lrgeon  to  the  Royal  London  Ophthalmic  Hospital 
Moorfielda. 


J 


Mai^ual  of  Surgery. 


Volume  II. 


I.     FKACTUKES. 

Frederick  A.  Southam. 

A  FRACTURE   iiiay    be    defined    as    tlie    sudden    aad 
violent  solution  of  continuity  in  a  bone. 

Varieties. — Many  ditierent  varieties  of  fracture 
arc  met  with,  and  they  may,  in  the  first  place,  be 
divided  into  simple  and  compound.  A  fracture 
is  said  to  be  simple^  when  it  is  unaccompanied  by 
an  open  wound  leading  down  to  the  broken  bone  ;  on 
the  other  hand,  it  is  termed  compound,  when  there  is 
an  open  wound  which  communicates  with  the  seat  of 
fracture.  A  fracture  may  be  rendered  compound  at 
the  time  of  inj  ury  by  the  same  violence  that  causes  the 
fracture,  either  lacerating  the  tissues  or  forcing  the  end 
of  one  of  the  fragments  through  the  skin  ;  in  other  cases 
a  fracture,  which  is  at  first  simple,  may  subsequently 
become  compound  from  sloughing  or  ulceration  of  the 
tissues  over  the  seat  of  injury. 

A  fracture  is  said  to  be  complete  when  it  involves 
the  entire  thickness  of  the  bone,  and  incomplete  when 
it  affects  a  portion  only  of  its  thickness  ;  the  former 
^■ariety  is  by  far  the  more  common,  the  latter  being 
met  with  in  cases  where  a  bone  is  partially  fissured,  as 
is  sometimes  seen  in  the  vault  of  the  skull,  or  in 
the  so-called  ^^ greenatick  "  fracture  (Fig.  I),  an  injury 
B— 21 


2  Maxctal  of  Sukgerv. 

often  occurring  in  young  subjucts,  wlierc  tiie  shaft  of 
a  long  bone  is  bent  and  partially  broken,  the  fracture 
only  involving  the  bone  on  the  convexity  of  the  curve  ; 
under  these  circumstances  the  periosteum  often  re- 
mains untorn,  and  there  is  little  or  no  displacement  of 
the  fragments.  Other  forms  of  incomplete  fracture 
are  the  splintered,  where  a  small  portion  or  splinter  of 
bone  is  separated,  ixndi  t\\Q  ^yerf orated  or  punctured,  the 
result  usually  of  a  gun-shot  wound. 

A  fracture,  again,  may  be  siiujle  dv  multiple  ;  in  the 
former  case  there  is  a  single  line  of  fracture  involving 


Fig.   1.— Greenstick  Fracture  of  the  Clavicle.     (From  Pick's 
"  Fractures  and  Dislocations.") 

a  single  bone  ;  in  the  latter  there  are  two  or  more 
fractures  involving  either  the  same  or  different  bones. 

When  the  bone  is  broken  into  several  or  innumer- 
able frajrments,  the  fracture  is  said  to  be  comminuted. 
A  fracture  is  described  as  transverse,  oblique,  longi- 
tudinal, spiral,  T-shaped,  stellate,  and  dentate,  accord- 
ing to  the  direction  which  the  line  of  fracture  takes  ; 
it  is  termed  impacted  when  one  fragment  is  driven 
into  and  fixed  in  the  other. 

When  occurring  in  the  neighbourhood  of  a  joint, 
e.g.  the  hip  or  shoukhir,  the  terms  iniracapstdar  and 
extracapsular  are  employed,  according  as  the  line  of 
fi-acture  is  internal  or  external  to  the  capsular  liga- 
ment. A  fracture  is  said  to  be  conip>licated  when  it 
is  accompanied  by  injury  to  some  other  important 
l)art,  e.g.  bv  ;i  dislocation  or  wound  of  a  neighbouring 


Causes  of  Fracture.  3 

joint,  or  by  wound  of  a  large  blood-vessel,  or  of  some 
internal  cavity  or  organ ;  a  simple  fracture  may  be 
complicated  by  an  external  wound,  the  fracture  not 
being  termed  compound  unless  the  wound  in  the 
soft  parts  leads  down  to  or  exposes  the  bone. 

Separation  of  the  epiphyses  may  be  considered  along 
with  fractures  ;  these  injuries,  which  occur  only  in 
young  subjects  before  ossification  is  completed,  may 
involve  the  ends  of  any  of  the  long  bones,  the  upper 
and  lower  epiphyses  of  the  humerus  being  those  which 
are,  perhaps,  most  frequently  separated  ;  less  frequently 
the  epiphyses  of  other  bones  are  involved,  e.g.  those  of 
the  OS  calcis,  acromion,  olecranon,  etc. 

Causes. — The  causes  of  fracture  may  be  divided 
into  two  great  classes,  predisposing  and  exciting. 

The  predisposing  causes  include  all  those  condi- 
tions, constitutional  or  local,  in  consequence  of  which 
the  osseous  tissue  becomes  unusually  fragile,  weakened, 
or  diseased ;  e.g.  old  age,  rickets,  certain  nervous  affec- 
tions, such  as  locomotor  ataxy,  general  paralysis  of 
the  insane,  etc.,  caries  or  necrosis,  malignant  tumours 
of  bone,  osteo-malacia,  atrophy  of  bone  from  any 
car.se,  absorption  of  bone  from  pressure  of  tumours,  or 
syphilis,  when  the  bone  becomes  the  seat  of  gummatous 
deposits. 

Other  predisposing  causes  of  fracture  are  the  male 
sex,  in  consequence  of  their  more  constant  exposure  to 
violence,  and  the  shape  and  situation  of  particular 
bones,  the  long  ones  of  the  extremities  being  more 
frequently  involved  than  short,  thick  bones,  like  the 
bodies  of  the  vertebra?,  etc. 

The  exciting  causes  of  fracture  are  external  violence 
and  muscular  action. 

External  violence,  by  far  the  more  common  cause, 
may  act  in  one  of  two  ways,  either  directly  or  in- 
dii-ectly.  When  due  to  direct  violence  the  fracture 
takes  place  at  the  part  struck,  e.g.  wlicn  a  blow  on  the 


4  Manual  of  Surgery. 

nose  fractures  the  nasal  bones  ;  under  these  circuui- 
stauceSjthe  soft  tissues  covering  the  bone  are  frequently 
bruised,  or  torn  and  lacerated,  as  the  result  of  the 
same  force  that  causes  the  fracture,  so  that  an  open 
wound  is  produced  which  leads  down  to  the  bone,  and 
the  fracture  is  consequently  often  compound. 

When  due  to  indirect  violence,  the  force  acting  at 
one  spot  is  transmitted,  and  causes  a  fracture  at  a  dis- 
tance from  it,  e.g.  when  a  person  falling  upon  the  hand 
or  shoulder  fractures  the  clavicle. 

Muscular  action  is  not  a  common  cause  of  fracture 
when  the  bones  are  in  a  healthy  condition,  except  in 
the  case  of  the  patella,  which  is  often  broken  by  the 
contraction  of  the  powerful  quadriceps  extensor  in  an 
attempt  to  save  the  body  from  falling  backwards. 
Much  less  frequently  some  of  the  other  bones,  e.g.  the 
olecranon,  os  calcis,  etc.,  are  fractured  as  the  result  of 
sudden  violent  contraction  of  the  muscles  inserted  into 
them.  When  the  bones  are  in  a  softened  or  diseased 
condition,  fracture  of  any  of  them,  even  the  long  ones 
of  the  extremities,  may  be  produced  in  the  same  way  ; 
and,  doubtless,  most  of  the  so-called  spontaneous  fraxi- 
lures  belong  to  this  class,  being  in  reality  due  to 
muscular  action  acting  upon  bones,  which  are 
weakened  from  some  of  the  causes  mentioned  above 
as  predisposing  to  fracture. 

In  the  same  way  separation  of  the  epipliyses  of  the 
long  bones  is  not  uncommon  in  infants  the  subjects  of 
congenital  syphilis,  owing  to  changes  of  an  inflamma- 
tory character  taking  place  at  the  junction  of  the 
shafts  with  the  e])iphyses ;  a  somewhat  simihir  condi- 
tion is  occasionally  met  with  in  children  Avho  are 
affected  with  "  acute  rickets  "  or  "  infantile  scurvy," 
in  consequence  of  effusions  of  blood  taking  place 
between  the  epiphyses  and  shafts,  and  also  beneath  the 
periosteum.* 

*  Barlow:  Med.-(Jliu-.  Trans.,  vol.  Ixvi,,  1883. 


Symptoms  of  Fracture.  5 

Intra-uterine  fracture.  —  Fractures  occasionally 
occur  in  the  foetus  before  birth,  in  some  cases  as  the 
result  of  external  violence,  e.rj.  a  fall  or  blow  on  the 
abdomen  of  the  mother ;  in  other  instances,  in  conse- 
qaence  of  abnormal  contraction  of  the  uterus,  or  even 
of  the  muscles  of  the  child  itself.  The  fracture,  which 
may  be  either  simple  or  compound,  may  or  may  not 
have  united  at  the  time  of  birth.  Intra-uterine 
fractures  must  not  be  confounded  with  those  occa- 
sionally produced  as  the  result  of  violence  sustained 
during  actual  delivery. 

Symptoms. — The  general  symptoms  of  fracture 
are  abnormal  mobility,  deformity,  crepitus,  and  loss  of 
power,  with  more  or  less  pain,  swelling,  and  ecchymosis 
at  the  seat  of  injury  ;  occasionally  the  patient  is  sen- 
sible of  a  distinct  crack  or  snap  produced  by  the  giving 
way  of  the  bone  at  the  moment  the  fracture  occurs. 

All  these  symptoms  are  not,  however,  present  in 
every  case,  being  modified  by  various  conditions. 

Abnormal  mobility  is  owing  to  the  loss  of  con- 
tinuity in  the  broken  bone,  and  can  usually  be  detected 
by  grasping  the  limb  on  either  side  of  the  seat  of  frac- 
ture, and  then  moving  the  fragments  to  and  fro,  or 
rotating  them  on  one  another.  It  is  not,  however,  a 
symptom  which  is  always  present,  for  it  is  wanting  in 
impacted  fracture,  and  cannot,  as  a  rule,  be  detected 
when  a  short  or  flat  bone  is  broken,  e.g.  in  the  bodies 
of  the  vertebrae,  vault  of  the  skull,  etc. 

Deformity.,  owing  to  displacement  of  the  fragments 
of  the  broken  bone,  is,  when  present,  always  an  im- 
portant sign  of  fracture.  It  may  be  the  direct  result 
of  the  violence  that  causes  the  fracture  ;  e.g.  in  im- 
pacted fracture  of  the  lower  end  of  the  radius  or  neck 
of  the  femur ;  or,  as  is  usually  the  case,  it  may  be 
due  to  subsequent  muscular  contraction  ;  e.g.  in  oblique 
fracture  of  the  tibia  when  the  lower  frao^inent  is  drawn 
upwards  above  the  upper  by  the  action  of  the  muscles 


6  Manual  of  Surgery. 

of  the  calf ;  or  it  may  be  the  result  of  the  weight  of 
the  limb  dragging  upon  one  of  the  fragments ;  e.g.  in 
fracture  of  the  clavicle,  when  the  outer  fragment  is 
drawn  down  by  the  weight  of  the  arm.  The  parti- 
cular deformity  will  depend  upon  the  direction  of  the 
line  of  fracture  and  also  upon  the  nature  of  the  dis- 
placement of  the  fragments  ;  thus  it  may  be  angular, 
or  transverse  or  lateral,  or  one  fragment  may  over- 
ride or  be  rotated  on,  or  widely  separated  from,  the 
other. 

In  all  cases  the  injured  part  should  be  compared 
witli  the  o})posite  side  of  the  body,  as  it  is  often  only 
by  a  careful  comparison  made  in  this  way  that  the 
deformity,  if  slight,  can  be  detected. 

Deformity  is  not,  however,  always  present ;  it  is 
often  absent  when  one  of  two  parallel  bones  is  broken  ; 
e.g.  in  fracture  of  the  fibula,  the  tibia,  acting  as  a  splint, 
often  i)re vents  any  displacement  of  the  fragments  from 
taking  place.  Again,  when  a  short  or  flat  bone  is  in- 
volved, there  is  often  no  displacement  and  consequently 
no  deformity. 

Crepitus  is  the  term  applied  to  the  rough  gratmg 
produced  when  the  ends  of  a  broken  bone  are  rubbed 
against  one  another.  When  present,  it  is  always  a 
valuable  sign  of  fracture,  but  it  is  often  absent ;  e.g. 
in  incomplete  fracture,  or  when  the  fragments  are  im- 
pacted, or  widely  separated,  so  that  they  cannot  be 
bi'ought  into  contact.  It  is  also  wanting  if  a  portion 
of  blood  clot,  muscle,  or  other  tissue,  is  interposed 
between  the  fragments ;  or  if  the  fracture  is  not 
recent,  and  the  ends  of  the  bone  have  become  covered 
o\er  with  inflammatory  exudation.  When  a  short  or 
flat  bone  is  fractured,  it  is  often  diflicult  to  detect 
crepitus,  as  also  in  cases  where  one  of  two  parallel  bones 
is  broken  ;  e.g.  in  fracture  of  the  fibula. 

I'he  true  or  bony  crepitus  met  with  in  fracture 
must  be  distinguished  from  false  or  "  silk^en  "  crepitus, 


Treatment  of  Fracture.  7 

as  it  is  sometimes  termed,  which  frequently  accom})a- 
nies  inflammation  of  the  sheath  of  a  tendon  ;  in  the 
latter  case  there  is  simply  a  fine  crackling  very  dif- 
ferent to  the  rough  grating  of  fracture.  When  in  the 
neighbourhood  of  a  joint;  care  must  be  taken  not  to 
mistake  the  crackling,  which  often  accompanies  eflTu- 
sion  into  its  interior  or  into  an  adjacent  bursa^  for 
the  crepitus  of  fracture. 

Loss  o.f  jjower  or  interference  with  function  is 
usually  present  to  a  greater  or  less  extent  in  the  part 
where  the  fracture  is  situated  ;  more  or  less  pain  will 
usually  be  complained  of,  and  in  most  instances  swell- 
ing and  ecchymosis  will  sooner  or  later  show  them- 
selves at  the  seat  of  injury. 

In  cases  of  separation  of  an  epiphysis,  the  general 
symptoms  are  identical  with  those  of  fracture,  except 
that  crepitus  is  either  absent  or  much  less  distinct, 
owing  to  the  fact  that  the  line  of  separation  runs 
through  cartilage  rather  than  bone ;  for  the  same 
reason,  the  ends  of  the  fragments  are  more  smooth 
and  rounded,  not  so  sharp  and  irregular  as  in  fracture. 

General  principles  of  treatment.— In  the 
treatment  of  any  fracture  there  are  three  indica- 
tions to  be  arrived  at,  and,  if  possible,  carried  out, 
viz.:  (1)  The  reduction  of  the  fracture  ;  (2)  the  main- 
tenance of  the  fragments  in  their  proper  position  until 
union  is  effected  ;  (3)  the  prevention  and  treatment  of 
any  complication,  constitutional  or  local,  that  may 
arise. 

1.  The  reduction  or  setting  of  the  fracture,  i.e. 
the  restoration  of  the  fragments  (when  displaced)  to 
their  proper  position,  should  always  be  eflected  with 
as  little  delay  as  possible,  otherwise  the  muscles,  as  the 
result  of  the  irritation  to  which  they  are  subjected, 
become  rigidly  contracted,  and  considerable  force  will 
then  be  required  to  overcome  the  spasm.  Great  care 
should  always  be  employed  in  manipulating  the  limb, 


8  AfAxcrAL  OF  Surgery 

for  if  it  is  rougbly  handled  there  is  a  risk   of  convert- 
ing a  simple  fracture  into  a  compound  one. 

In  ordinary  cases,  e.g.  in  fracture  of  the  long  bones 
of  the  extremities,  reduction  is  effected  by  the  employ- 
ment of  extension  and  counter-extension.  The  surgeon 
makes  extension  by  drawing  steadily  and  without 
jerking  upon  the  limb  below  the  seat  of  fracture, 
while  an  assistant  makes  counter-extension  ;  viz.  fixes 
the  limb  on  the  proximal  side  of  the  fracture.  In  this 
way  the  extending  force,  which  acts  only  on  the  lower 
fragment,  is  maintained  until  the  ends  of  the  bone  are 
drawn  opposite  to  one  another  ;  by  a  little  mani[)ula- 
tion,  as,  for  example,  by  pressing  gently  on  one  or 
both  of  the  fragments,  they  can  usually  be  brought 
into  proper  position,  and  some  further  means  must 
then  be  adopted  in  order  to  maintain  them  so. 

Inasmuch  as  spasm  of  the  muscles  is  the  chief 
cause  of  displacement  in  fracture,  reduction  will  often 
be  facilitated  by  the  adoption  of  measures  which  tend 
to  produce  muscular  relaxation.  In  some  cases  this 
can  be  effected  by  attention  to  the  position  of  the 
part ;  e.g.  in  fracture  of  the  tibia  and  fibula,  by  bend- 
ing the  knee  so  as  to  relax  the  muscles  of  the  calf ;  occa- 
sionally division  of  the  tendons  may  be  required  before 
reduction  can  be  effected  ;  e.g.  tenotomy  of  the  tendo 
A  chillis  is  occasionally  necessitated  in  the  same  frac- 
ture. Anaesthetics  will  often  be  found  useful  in  similar 
circumstances,  for  when  the  patient  is  under  their 
influence  muscular  spasm  at  once  disappears. 

Reduction  is,  however,  occasionally  impossible,  as, 
for  example,  in  certain  cases  of  firmly  imyiacted  frac- 
ture ;  under  these  circumstances  it  is  often  better  not 
to  attempt  it,  preparing  the  patient  for  the  defonnity 
which  will  be  permanent. 

2.  Tlte  maintenance  of  the  fragments  in  their  projjer 
po.ntion  after  the  fracture  has  been  set  has  next  to  be 
attended  to,  and  this  may  be  effected  in  various  ways ; 


Treatment  of  Fracture.  ■       g 

e.g.  bj  means  of  splints,  bandages,  or  some  form  of 
special  apparatus.  Splints  composed  of  many  different 
kinds  of  material  are  employed  for  this  purpose ;  e.g. 
■wood,  tin,  zinc,  wire,  guttapercha,  felt,  mill-board, 
leather,  etc. 

Bandages  containing  some  material,  e.g.  plaster  of 
Paris,  starch,  gum  and  chalk,  paraffin,  silicate  of 
sodium  or  potassium,  etc.,  which  hardens  when  dry, 
forming  a  firm,  solid  application  accurately  moulded 
to  the  part,  are  much  used  at  the  present  time  ;  if 
necessary,  they  can  be  strengthened  by  the  insertion 
of  pieces  of  iron,  tin,  felt,  or  mill-board,  between  the 
layers  of  bandage. 

Some  surgeons  at  once  put  up  the  fracture  in  one 
of  the  different  varieties  of  solidifying  apparatus ;  e.g. 
a  plaster  of  Paris  bandage  ;  others  prefer  to  apply 
some  form  of  splint,  e.g.  the  ordinary  wooden  ones 
for  a  few  weeks,  and  then,  when  repair  is  well  ad- 
vanced, to  replace  them  with  a  stiff  bandage. 

One  great  advantage  of  splints  is  that  the  seat  of 
injury  can  be  left  exposed,  whereas  if  a  stiff  bandage 
is  emjjloyed  the  fracture  is  concealed  from  view,  unless 
the  bandage  is  interrupted,  or  slit  up  along  its  whole 
length  after  it  has  set,  so  as  to  allow  of  its  removal 
from  time  to  time. 

As  a  general  rule,  splints  should  be  employed  in 
cases  where  the  soft  tissues  are  much  swollen,  bruised, 
or  ecchymosed,  or  where  there  is  much  displacement  of 
the  fragments  and  difhculty  is  experienced  in  reducing 
and  maintaining  them  in  position,  care  being  taken 
that  in  the  former  case  the  bandages  Avhich  fix  the 
splints  are  not  applied  too  tightly.  The  seat  of  injury 
being  left  uncovered,  some  e\'aporating  lotion  can  be 
ap])lied,  the  condition  of  the  part  can  be  examined 
from  day  to  day  without  removing  the  apparatus,  and 
if  any  displacement  of  the  fragments  takes  place,  it 
will  at  once  be  evident  and  can  then  be  corrected.      If 


TO    .  Manual  of  Surgerv. 

some  form  of  stitf  bandage  is  applied  when  the  parts 
are  much  swollen,  it  will  become  loose  when  the 
swelling  subsides  and  consequently  allow  of  move- 
ment and  displacement  of  the  ends  of  the  fractured  bone. 

A  stiff  bandage  may,  however,  frequently  be  applied 
at  once  with  very  good  results,  if  none  of  the  con- 
ditions just  mentioned  are  present ;  and  in  the  case  of 
the  lower  extremity  it  possesses  this  additional  advan- 
tage, that,  being  light,  it  does  not  necessitate  confine- 
ment to  bed,  and  the  patient,  with  the  assistance  of 
crutches,  will  often  be  able  to  get  about  in  the  course 
of  a  few  days. 

Many  modifications  of  the  latter  method  of  treat- 
ment are  now  employed,  and  a  very  useful  one  is  that 
recommended  by  Mr.  Croft,  in  cases  of  fracture  of  the 
lower  extremity.*  In  the  so-called  "Croft's  splints," 
a  double  layer  of  coarse  flannel,  shaped  so  as  to  tit 
the  limb  and  form  a  kind  of  lateral  splint,  is  ap- 
plied to  each  side  of  the  leg  and  foot,  the  outer 
layer  having  been  previously  saturated  with  a  solu- 
tion of  plaster  of  Paris  and  water  of  the  consistence 
of  thick  cream.  A  muslin  bandage  is  applied  outside 
the  flannel  so  as  to  maintain  it  in  close  contact  with  the 
limb  while  the  plaster  is  setting,  and  at  the  same  time 
care  must  be  taken  that  the  fracture  is  kept  in  pro})er 
position.  After  the  bandage  has  set,  it  is  cut  up  along 
its  centre,  viz.  in  front  of  the  limb  at  the  line  of 
junction  of  its  two  lateral  halves,  so  as  to  allow  of  its 
removal  from  time  to  time  for  the  purpose  of  exam- 
ining the  fracture  and  the  condition  of  the  limb. 

In  the  application  of  splints  there  are  certain  rules 
which  should  always  be  observed  ;  viz.  1.  The  splints 
should  be  well  padded,  especially  where  they  press 
upon  ])oints  of  bone.  2.  They  should,  if  possible,  in- 
clude the  joints  above  and  below  the  fracture,  so  as  to 
completely  fix  the  limb.  3.  No  bandages  should  be 
*  Medico-Chir.  Traus.,  vol.  Ixiv. 


Treatment  of  Fracture.  t\ 

applied  beneath  them.  4.  The  seat  of  fracture  should 
be  left  uncovered.  5.  The  extremities  of  the  limV), 
e.g.  the  lingers  or  toes,  should  be  left  exposed  to 
view.  When  plaster  or  other  forms  of  solidifying 
bandages  are  used,  care  must  be  taken  not  to  apply 
them  too  tightly,  otherwise,  when  they  set,  con- 
striction of  the  limb  may  be  produced  ;  to  prevent  this, 
it  is  a  good  plan  to  first  envelope  the  limb  in  a  layer 
of  cotton  wool,  or  to  apply  dry  next  to  the  skin  several 
layers  of  an  ordinary  flannel  bandage. 

Whatever  form  of  apparatus  is  employed,  the  frac- 
ture should  always  be  examined  the  day  after  it  has 
been  put  up,  and  subsequently  from  time  to  time  ;  if  the 
limb  is  found  to  be  painful  aud  swollen,  and  es- 
pecially if  the  toes  or  fingers  are  cold,  numb,  con- 
gested, or  oedematous,  the  bandages  or  splints 
should  be  eased  or  removed  and  re-applied,  other- 
wise there  is  a  risk  of  gangrene  supervening,  for 
the  occurrence  of  these  symptoms  shows  that  too 
much  pressure  has  been  used  and  that  the  circula- 
tion through  the  limb  has  become  impeded. 

The  special  forms  of  apparatus  which  may  be  re- 
quired will  be  mentioned  under  the  different  fractures. 

The  fracture  bed,  in  cases  of  fracture  of  the 
lower  extremity,  should  be  fiat  and  firm ;  if  it  tends 
to  sink  in  the  centre,  a  piece  of  board  should  be 
introduced  between  the  mattress  and  the  bedstead. 
Care  should  be  taken  that  the  sheets  do  not  crease, 
and,  if  possible,  a  strong  cord  with  a  short  stick 
attached  to  its  lower  end  should  be  suspended  over 
the  bed,  to  assist  the  patient  in  raising  or  moving  his 
body  when  requisite. 

Treatment  of  coiiipoimcl  fractures. — The 
limb  may  be  put  up  in  a  similar  manner  either  in 
splints  or  in  some  form  of  stiff"  bandage ;  if  the  latter 
method  is  employed,  an  opening,  or  "  window,'' 
should    be    cut    in   the    bandage    exactly    over   the 


T2  Manual  of  Surgery. 

fracture,  or  tlie  bandage  should  be  interrupted  at 
the  same  spot  with  strips  of  iron  hoop  or  pieces  of 
strong  wire,  which  are  inserted  between  its  layers 
as  it  is  applied,  in  order  to  allow  of  the  wound  being 
examined  and  dressed  when  necessary. 

As  regards  the  treatment  of  the  wound  itself,  this 
will  depend  upon  the  nature  of  the  injury. 

If  there  is  a  mere  puncture  in  the  skin  caused  by 
tlie  sliarp  end  of  one  of  the  fragments,  it  may  often  be 
closed  at  once  with  a  pad  of  lint  dipped  in  the 
compound  tincture  of  benzoin  or  collodion ;  under 
this  the  wound  \\all  often  rapidly  heal,  and  the  fracture 
being,  as  it  were,  converted  into  a  simple  one, 
will  in  many  cases  quickly  unite  without  any 
suppuration.  If,  however,  under  this  treatment 
the  temperature  rises,  and  the  j)arts  about  the 
seat  of  fracture  become  hot,  red,  painful,  and 
swollen,  the  pad  of  lint  should  be  removed,  and  if  there 
is  any  evidence  of  suppuration,  the  wound  should  be 
opened,  and  free  vent  having  been  aflbrded  to  the  pus, 
it  should  be  treated  in  the  manner  next  described,  or 
this  method  may  be  adopted  from  the  first. 

If  the  wound  is  of  some  dimensions,  and  if  its  edges 
are  lacerated  and  the  surrounding  tissues  much  bruised 
and  swollen,  no  attempt  should  be  made  to  close  it ; 
under  these  circumstances,  if  seen  within  the  first 
twenty-four  hours  (all  bleeding  having  been  arrested), 
the  wound  should  be  carefully  cleansed  and  then 
thorouglily  syringed  out  with  a  solution  of  carbolic 
acid  (1  in  20)  or  some  other  antiseptic  lotion,  care 
being  taken  that  the  fluid  comes  well  into  contact  with 
all  its  recesses.  If  a  longer  period  has  elapsed,  a 
stronger  solution  should  be  used,  e.g.  one  consisting 
of  carbolic  acid  and  spirit  (1  in  5). 

Some  means  must  then  be  provided  for  efficient 
drainage  ;  one  or  more  of  the  ordinary  drainage  tubes 
may  be   inserted,  and  the  wound  should   be  dressed 


Treatment  of  Fracture.  13 

and  afterwards  treated  according  to  the  Listerian 
method. 

In  cases  where  the  ends  of  the  bones  are  much 
comminuted,  the  fragments,  w^hen  of  small  size  or  lying 
loose  and  separated  from  the  periosteum,  should,  if  pos- 
sible, be  removed,  for  if  left  they  will  probably  necrose. 
If  the  wound  is  small  and  the  bone  projects  through  it, 
it  is  sometimes  necessary  to  enlarge  the  opening  before 
reduction  can  be  effected ;  and  if  it  is  still  impossible, 
the  projecting  portion  of  bone  should  be  removed 
with  a  saw.  When  difficulty  is  experienced  in  main- 
taining the  ends  in  apposition,  it  will  sometimes  be 
necessary  to  bring  them  together  wdth  sutures  of  silver 
wire. 

The  wound  must  afterw-ards  be  treated  on  general 
principles,  care  being  taken  to  prevent  any  accumu- 
lation or  burrowing  of  pus,  and  the  dressing  being 
changed  when  necessary  with  as  little  disturbance  of 
the  fracture  as  possible.  In  cases  of  severe  compound 
fracture,  amputation  of  the  limb  is  occasionally  re- 
quired ;  this  is,  as  a  rule,  indicated  when  there  is  very 
extensive  laceration  and  destruction  of  the  soft  parts 
with  much  splintering  of  the  bone,  and  especially  if 
the  main  vessels  of  the  limb  are  wounded,  or  an  ad- 
jacent large  joint  {e.g.  the  knee)  laid  open.  In  every 
instance  the  age  and  constitution  of  the  patient  should 
be  taken  into  account,  as  well  as  the  situation  of  the 
injury.  A  severe  compound  fracture  in  a  young 
person  of  sound  constitution  may  often  be  successfully 
treated,  whereas  in  a  person  advanced  in  years,  or 
broken  down  in  health,  the  attempt  to  save  the  limb 
will  be  useless  and  often  attended  with  danger  to  life; 
so  also  the  prospect  of  recovery  is  ahvays  much  greater 
in  the  upper  than  in  the  lower  extremity,  owing  to  the 
greater  repai-ative  power  of  the  former. 

Couiplicatioii^  dui'iug:  treatiiii'iil. — During 
the  treatment  of  any   fi'acture,  various   accidents  or 


14  Manual  of  Surgery. 

conn:>lications  may  arise,  some  of  which  are  local  while 
others  are  of  a  general  kind. 

(Edema  and  swelling  of  the  limb  are  among  the 
most  common;  they  may  be  due  to  bruising  and  ex- 
travasation of  blood,  mingled  with  more  or  less  of 
inflammatory  effusion,  or  to  simple  passive  congestion 
from  tight  bandaging.  Under  these  circumstances 
not  only  does  the  limb  become  tense  and  swollen,  but 
in  many  instances  large  blebs  or  bullae  appear  on  its 
surface,  containing  a  clear  or  blood-tinged  serum. 

When  these  conditions  are  present  the  bandages 
should  be  slackened  and  some  evaporating  lotion 
applied ;  if  the  soft  tissues  are  much  bruised,  the  skin 
should  be  painted  over  every  day  with  tmct.  benz.  co. ; 
when  bulliB  form,  they  may  be  pricked  and  their 
contents  allowed  to  escape,  or  left  to  themselves,  for 
they  generally  burst  or  dry  up  and  disappear  in  the 
course  of  a  few  days. 

Ulcey'ation  and  sloughing  of  the  soft  tissues  over 
the  seat  of  injury  may  ensue,  and  as  a  consequence  a 
simple  fracture  may  become  converted  into  a  compound 
one.  Ulcers  of  a  troublesome  nature  are  also  apt  to 
form  over  bony  prominences,  in  cases  where  the  splinta 
are  not  well  padded  ;  and  unless  care  is  taken,  bed-sores 
may  also  appear  over  the  sacrum,  buttock,  hips,  etc., 
especially  in  old  or  debilitated  subjects,  when  the 
fracture  involves  long  confinement  in  the  recumbent 
posture. 

Spasm  of  the  mnscles  of  an  obstinate  nature  is 
sometimes  present,  and  as  a  consequence  considerable 
difficulty  is  often  encountered  in  keeping  the  fracture 
in  proper  position.  As  a  general  rule,  it  can  be  over- 
come by  moderate  pressure  by  means  of  bandages, 
though  in  exceptional  cases  tenotomy  may  be  re- 
quired. 

Gangrene  of  the  limb  is  occasionally  met  with, 
and,  as  a  rule,  it  is  the  result  of  imjtroper  treatment, 


Fat  Embolism.  15 

?.//.  loo  tight  baiulagiiig.  Tlicrnfore,  as  already 
mentioned,  the  part  should  be  frequently  examined, 
especially  during  the  first  few  days  after  the  frac- 
ture has  been  put  up,  and  if  there  is  any  evidence  of 
coldness,  numbness,  livid ity,  or  swelling  of  the  limb, 
or  of  the  fingers  and  toes,  the  bandages  should  at  once 
be  relaxed,  for  if  unrelieved  gangrene  is  liable  to 
supervene.  Much  less  frequently  gangrene  is  due  to 
laceration  of  the  main  artery  of  the  limb  by  one  of  the 
fragments,  or  to  the  vessels  being  nipped  between  or 
pressed  upon  by  the  ends  of  the  bone. 

Venous  thrombosis  and  embolism  are  sometimes  met 
with.  In  most  cases  of  fracture,  thrombosis  doubtless 
occurs  to  a  greater  or  less  extent  in  some  of  the  veins 
in  the  neighbourhood  of  the  injury.  In  rare  cases  a 
portion  of  clot  may  become  detached,  and,  acting  as  an 
embolus,  it  may  be  carried  onwards  by  the  stream  of 
blood  along  the  large  veins  until  it  reaches  the  heart 
or  one  of  the  branches  of  the  pulmonary  artery  ;  there 
it  may  become  arrested  and  give  rise  to  sudden  death 
from  asphyxia.  Fortunately  this  complication  of 
fracture  is  very  uncommon,  but  two  cases  of  its  occur- 
rence in  simple  fracture  of  the  lower  extremity,  and 
followed  by  death,  have  come  under  my  immediate 
notice.* 

Fat  embolism  is  the  term  applied  to  a  condition  met 
with  as  a  complication  of  simple,  though  much  more 
frecjuently  of  compound,  fracture,  in  which  the 
ca])illaries  of  the  lung,  kidney,  brain,  spinal  cord,  and, 
in  fact,  of  almost  every  part  of  the  body  have  been 
found  plugged  with  fatty  emboli  or  globules  of  liquid 
fat. 

It  is  believed  that  it  may  occur  to  a  slight  degree 

in  all  cases  of  fracture,  but  especially  so  in  severe  cases 

accompanied  by  much  crushing  of  the  bone  and  its 

medullary  cavity,  when  fluid  fat  is  set  free  in  large 

*  Lancet,  vol.  i.,  p.  296;  1879. 


1 6  Manual  of  SurgeHV. 

quantities.  Under  these  circumstances  the  oil  globules, 
gaining  access  into  the  venous  circulation  through  the 
openings  in  the  vessels  about  the  seat  of  the  injury,  act 
as  emboli  and  are  carried  on  by  the  blood  stream  until 
they  become  arrested  in  the  capillaries  of  the  various 
tissues  and  organs. 

In  order  to  detect  their  presence,  the  parts  aftei 
removal  should  be  stained  with  osmic  acid  ;  the  fatty 
matter  will  then  be  evident  in  the  form  of  black 
globules  and  irregular  masses  of  various  sizes  blocking 
up  the  capillaries  and  minute  vessels. 

The  symptoms  of  fat  embolism  are  somcwjiat 
obscure  ;  they  usually  come  on  as  a  kind  of  secondary 
shock  from  twenty-four  to  forty-eight  hom-s  after  the 
occurrence  of  the  injury,  consisting,  as  a  rule,  of 
dyspnoea  with  irregular  action  of  the  heart,  and  pallor, 
or  cyanosis  of  the  face;  occasionally  slight  hsemojjtysis 
has  also  been  observed  ;  the  temperature  may  be 
lowered  or  run  somewhat  high  ;  in  fatal  cases  the 
patient  rapidly  becomes  collapsed,  and  sinking  into  a 
condition  of  coma,  death  may  be  preceded  either  by 
convulsions  or  paralysis.  When  recovery  takes  place, 
it  would  appear  that  the  fatty  matter  is  eliminated  by 
the  kidney,  for  its  presence  in  the  urine  has  been 
detected  for  several  weeks  after  the  injury. 

As  regard  treatment,  it  has  been  suggested  that 
intravenous  injections  of  ether  might  be  of  service 
along  with  artificial  respiration  ;  when  cyanosis  is  a 
prominent  symptom,  venesection  might  possibly  give 
relief. 

In  cases  of  compound  fracture,  other  complications 
are  frequently  met  with.  Necrosis  often  results,  small 
pieces  of  bone,  which  have  been  detached  or  stripped 
of  their  periosteum,  subsequently  dying.  Suppurative 
periostitis  or  acute  osteo-7vyelitis  with  extensive  sup- 
puration may  ensue,  and,  as  a  consequence,  large  por- 
tions of  bone  may  necrose.      Under  theiie  circumstances 


Complications  of  Fracture.  17 

union  will  be  retarded,  the  presence  of  the  dead 
bone,  which  is  often  long  in  separating,  uiterfering 
with  the  process  of  repair.  Extensive  sloughing  of  the 
soft  tissues  may  also  result,  and,  as  in  other  injuries, 
erysipelas  may  also  attack  the  wound. 

The  general  complications  which  are  common  to 
all  varieties  of  fracture  are  as  follows :  shock;  traumatic 
delirium,  especially  liable  to  occur  in  persons  of 
intemperate  habits  ;  hypostatic  congestio7i  of  the  lungs, 
often  met  with  in  old  persons  as  the  result  of  confine- 
ment in  the  recumbent  position.  Retention  of  urine 
for  some  days  after  the  accident  is  not  uncommon,  in 
some  cases  as  the  result  of  shock,  in  others  in  con- 
sequence of  confinement  to  bed  ;  tetanus  may  occur  as 
after  other  injuries,  but  is  a  rare  complication. 

In  cases  of  compound  fracture  there  is,  in  addition, 
the  risk  of  severe  traumatic  fever,  and  this  may  run 
on  to  septiccemia  and  pycemia,  complications  which 
frequently  prove  fatal. 

After  union  has  been  eflfected,  and  the  splints  have 
been  removed,  other  complications  are  frequently  met 
with. 

(Edema  of  the  limb  is  often  present  for  a  time,  with 
stiffness  of  the  joints  above  and  below  the  seat  of 
fracture,  the  latter  condition  being  due  to  long 
confinement  in  a  fixed  position,  and  to  the  formation 
of  adhesions  around  the  tendons  and  between  them 
and  their  sheaths.  As  a  rule,  these  conditions  will 
gi-adually  disappear  if  the  limb  is  used,  and  friction 
with  some  stimulating  liniment  emploj^ed  along  with 
passive  movement.  If  the  oedema  persists,  one  of  Mar- 
tin's indiarubber  bandasres  will  often  be  found  useful. 

Pain  about  the  seat  of  fracture,  of  a  somewhat 
rheumatic  character,  is  frequently  complained  of  for  a 
considerable  period,  especially  in  the  case  of  old  people  ; 
this  also  will,  as  a  rule,  gradually  disappear  in  course 
of  time ;  but  when  severe  and  obstinate,  relief  may 
c— 21 


1 8  Manual  of  Surgery. 

ofton  be  obtained  by  tlie  internal  administration  of 
iodide  of  potassium,  and  counter-irritation  over  the 
seat  of  fracture  by  painting  with  tincture  of  iodine, 
or,  if  much  thickening  is  present,  by  the  application 
of  some  mercurial  ointment.- 

Paralysis  of  the  limb  is  occasionally  met  with, 
especially  in  the  upper  extremity,  as  the  result  of 
implication  of  the  nerves  in  the  callus  which  is 
formed  at  the  seat  of  fracture  ;  under  these  circum- 
stances it  is  sometimes  necessary  to  cut  down  upon 
the  fracture  in  order  to  liberate  the  nerve. 

Crvtch  par«72/*'is>  '^'•^^'  loss  of  power  in  the  arm 
from  the  pressure  of  tlie  ciiitches  upon  some  of  the 
nerves  wliicli  supply  it,  is  often  met  with  in  fracture 
of  the  lower  extremity,  if  the  patient  is  allowed  to 
walk  about  on  crutches  without  hand-bars,  or  the 
arm-pieces  of  which  are  not  well  padded.  Any  or  all 
of  the  nerves  supplying  the  arm  may  be  involved  ; 
paralysis  of  the  musculo-spiral  is  perhaps  most 
common^  the  patient  then  presenting  evidence  of 
wrist-drop. 

SJiortening  of  the  limb  often  ensues,  in  many  cases 
as  the  result  of  im2:)roper  treatment,  e.g.  allowing  the 
ends  of  the  bone  to  overlap.  After  separation  of  an 
epiphysis  it  is  sometimes  met  with  as  tlie  result  of 
actual  arrest  of  growth,  the  epiphysial  cartilage  being 
so  injured  that  the  development  of  the  bone  is  after- 
ward fi  interfered  with. 

Morbid  growths  springing  from  the  bone,  and 
usually  of  a  sarcomatous  or  cartilaginous  nature,  may 
in  rare  cases  develop  at  the  seat  of  fracture,  at  a 
variable  period  after  tht-  injury. 

Process  of  repair. — The  uniting  material  by 
which  union  is  efiected  in  fracture  is  toi-med  ca/Zw-s  ; 
this  consists,  in  the  early  stage,  of  simple  inflammatory 
exudation  or  lymph,  and  the  process  of  repair  in  simple 
fracture  is  essentially  identical  with  that  which  occurs 


Repair  in  Fracture.  iq 

in  the  healing  of  wounds  by  first  intention  in  the 
soft  parts,  except  that  the  lymph  subsequently  develops 
into  bone  instead  of  remaining  as  ordinary  cicatricial 
tissue.  As  the  immediate  result  of  the  injury,  more 
or  less  extravasation  of  blood  takes  place  into  the 
tissues  round  about  and  between  the  ends  of  the  bone, 
the  periosteum  being  torn  and  the  adjacent  muscles 
lacerated  to  a  greater  or  less  extent.  Inflammation 
ra])idly  ensues,  and  there  is  an  exudation  of  lymph 
into  the  adjacent  parts  poured  out  by  the  vessels  of 
the  bone,  periosteum,  and  surrounding  tissues.  The 
consequence  is,  that  between  and  around  the  ends  of 
the  bone,  as  well  as  into  the  medullary  cavity,  there  is 
poured  out  a  quantity  of  plastic  matter  which  mingles 
with  the  blood  clot  already  present ;  in  the  course  of 
a  few  days  this  gradually  begins  to  consolidate,  the 
blood  clot  becoming  either  absorbed,  or  remaining  and 
assisting  in  forming  the  callus,  the  term  applied  to 
the  uniting  medium,  as  it  becomes  firmer  and  fibrous. 

At  the  same  time,  the  periosteum  at  the  seat  of 
injury  gradually  disappears,  becoming  lost  in  the  mass 
of  callus,  which,  as  it  consolidates,  forms  a  kind  of  fusi- 
form sheath  or  natural  splint  round  the  ends  of  the  bone. 

The  term  ^;7-omszo?ia/  or  temporary  callus  is 
applied  to  that  which  is  poured  out  around  the  bone 
and  within  its  medullary  cavity  ;  while  that  which  is 
formed  between  the  broken  ends  is  described  as 
definitive  or  permanent  callus. 

As  the  process  continues,  a  new  periosteum  is 
formed  from  the  outer  or  superficial  layer  of  callus, 
which,  after  developing  into  fibrous  tissue  (and  occa- 
sionally in  children  into  cartilage  or  fibro-cartilage), 
subsequently  ossifies  and  forms  new  bone,  a  deposition 
of  lime  salts  taking  place  in  its  substance.  This 
process  of  ossification  usually  commences  about  the 
end  of  the  first,  and  is  often  considerably  advanced  by 
the  end  of  the  third  week 


20  Manual  of  Surgery. 

The  result  is  that  in  the  course  of  four  to  eight 
weeks  the  ends  of  the  bone  become  firmly  united  by 
a  mass  of  newly-formed  osseous  tissue,  which  at  first 
is  spongy  and  cancellous,  and  can  often  be  felt  as  a 
distinct  swelling  surrounding  the  bone  at  the  seat  of 
mjury. 

The  last  stage  in  the  process  consists  in  the 
disappearance  of  the  provisional  callus ;  this,  after 
becoming  dense  and  compact,  undergoes  a  gradual 
process  of  absorption,  and  in  the  course  of  some 
months  more  or  less  completely  disappears,  so  that  the 
bone  resumes  its  natural  form,  and  the  medullary 
canal  is  restored.  By  the  time  this  is  effected,  the 
permanent  callus  poured  out  between  the  ends  of  the 
fragments  will  have  acquired  sufficient  strength  to 
maintain  the  continuity  of  the  bone ;  hence  it  would 
appear  that  it  is  the  function  of  the  former  to  support 
the  fragments  and  to  keep  them  in  apposition,  in 
fact,  act  the  part  of  a  temporary  splint,  until  union  is 
effected. 

The  amount  of  provisional  callus  which  is  formed 
depends  upon  the  nature  of  the  fracture  and  also 
upon  its  after-treatment.  If  there  is  no  displacement 
nor  comminution  of  the  fi-agments,  and  if  they  are  kept 
in  a  state  of  complete  rest,  it  may  be  entirely  absent. 
If,  however,  they  are  much  splintered,  or  not  in  perfect 
apposition,  or  if  some  movement  is  allowed,  then  it  is 
often  considei'able  in  amount,  being  poured  out  around 
the  splinters  or  ends  of  the  bone.  In  fracture  of 
certain  bones,  e.g.  the  ribs  and  clavicle,  provisional 
callus  is,  for  obvious  reasons,  always  present,  and, 
as  one  would  expect,  it  is  more  frequently  met  with 
in  children  than  in  adults,  owing  to  the  difficulty 
often  encountered  in  the  former  in  keeping  the  frac- 
ture completely  at  rest. 

In  the  case  of  compound  fractures.,  when  the 
external  wound,  being  of  small  size,  is  at  once  closed 


Eepair  in  Fracture.  21 

or  sealed,  and  the  fracture  is,  as  it  were,  converted 
into  a  simple  one,  repair  may  take  place  in  a  similar 
manner. 

In  many  cases,  however,  and  especially  wlien  the 
wound  is  large  and  accompanied  by  much  laceration  of 
the  soft  tissues  or  splintering  of  bone,  union  is  efiected 
by  a  process  of  suppuration  and  granulation,  identical 
with  what  occurs  in  healing  by  second  intention  in  the 
soft  tissues.  Suppuration  is  excited  at  the  seat  of 
injury,  and  granulations  spring  up  from  the  ends  of 
the  bone,  as  w^ell  as  from  the  adjacent  soft  parts ;  the 
consequence  is  that  the  whole  of  the  interior  of  the 
wound  becomes  lined  with  a  layer  of  granulation 
tissue  secreting  pus,  which  bathes  the  ends  of  the 
bone. 

By  the  growth  and  development  of  these  granula- 
tions into  hbrous  tissue  the  cavity  of  the  wound  is 
gradually  filled  up,  and  at  the  same  time  union  is 
effected.  The  subsequent  changes  are  identical  with 
those  which  occur  in  simple  fracture^  the  fibrous  tissue 
undergoing  a  process  of  ossification,  so  that  the  ends  of 
the  bone  become  surrounded  and  united  by  a  mass  of 
callus,  which,  after  developing  into  bone,  is  more  or 
less  completely  absorbed,  and  disappears. 

The  process  is,  however,  frequently  complicated  by 
necrosis ;  small  portions  of  bone,  which  have  been 
separated  at  the  time  of  injury,  or  had  their  su|)piy 
of  blood  interfered  with,  often  die ;  or  the  ends  of  the 
bone  themselves,  having  been  stripped  of  theperiosteum, 
or  injured  to  such  an  extent  that  their  vitality  is 
destroyed,  may  subsequently  necrose. 

Under  these  circumstances  the  wound  will  not 
Ileal  so  long  as  the  dead  portions  of  bone  are  present, 
for,  acting  as  sources  of  irritation,  they  keep  up 
suppuration.  If  of  small  size,  they  may  make  their 
way  externally ;  but  when  of  some  dimensions,  it  will 
often  be  necessary  to  enlarge  the  wound  and  extract 


2  2  Manual  of  Surgery. 

them  with  a  pair  of  forceps.  When  the  ends  of  the 
fragments  themselves  necrose,  the  process  is  usually  a 
very  tedious  one,  for  then  separation  is  slowly  effected, 
the  dead  portions  of  bone  often  becoming  ensheathcd 
by  new  osseous  tissue  thrown  out  round  about  them  ; 
under  these  circumstances  they  will  frequently  have 
to  be  removed  by  the  operation  of  sequestrotomy. 

The  length  of  time  required  for  union  varies  in  the 
different  bones,  and  also  depends  upon  the  nature  of 
the  fracture  and  the  age  of  the  patient.  In  simple 
fractures  of  the  low^er  extremity  occurring  in  healthy 
adults,  the  average  period  is  from  eight  to  twelve 
weeks ;  in  the  case  of  the  upper  extremity,  from  four 
to  eight  weeks.  In  the  case  of  children,  where  union 
is  more  quickly  effected,  the  time  required  is  somewhat 
shorter,  while  in  old  persons  it  will  be  longer. 

In  severe  compound  fractures  the  period  will  often 
be  three  or  four  times  that  required  in  simple  fracture. 

Defects  in  the  process  of  union. — The  pro- 
cess of  repair  may  in  certain  cases  be  delayed  beyond 
the  usual  period,  and  occasionally  it  is  not  effected  by 
means  of  bone,  or  doos  not  take  place  at  all ;  under 
the  latter  circumstances  the  fracture  is  said  to  be 
ununited. 

Delayed  union  may  be  due  to  any  of  the  causes 
mentioned  below  as  giving  rise  to  non-union. 

The  treatment  is  partly  constitutional,  partly  local. 
Attention  should  be  paid  to  the  general  health,  and  an 
attempt  made  to  promote  union  by  stimulating  the 
reparative  process,  e.g.  by  rubbing  the  ends  of  the 
bone  gently  together;  shampooing  the  limb  around 
the  seat  of  fracture;  "hammering"  the  limb,  i.e. 
surrounding  it  with  a  piece  of  felt,  and  then  per- 
cussing it  forcibly  with  a  mallet  over  the  seat  of 
fracture  ;  blistering  the  limb,  or  painting  with  tincture 
of  iodine  over  the  same  spot,  etc. 

In  cases  where  the  patient  has  been  contined  to  bed 


A^ON- Union  op  Fracture.  23 

in  splints  for  the  usual  period,  union  often  results  if  ho 
is  allowed  to  get  about  on  crutches  with  the  liinlj  in  a 
stiff  bandage.  When  the  fracture  has  not  been  kept 
in  a  state  of  complete  rest,  repair  will  often  take  place 
if  it  is  put  up  in  some  immovable  apparatus. 

IVoii-unioii  may  appear  under  three  different 
forms. 

1.  In  ligamentous  union,t\\Q  most  common  variety, 
the  ends  of  the  bone  are  merely  united  by  fil)rous  tissue, 
so  that  a  certain  amount  of  movement  is  possible 
between  them. 

2.  In  false  joint,  or  pseudarthrosis,  a  somewhat 
similar  condition  is  present,  but  the  movement  is  more 
free,  the  ends  of  the  bones  becoming  smooth,  rounded 
and  enclosed  in  a  kind  of  capsule  formed  of  fibrous 
tissue,  not  unlike  that  of  a  joint.  In  well-marked 
cases  their  surfaces,  of  which  one  is  often  convex,  the 
other  concave,  may  be  invested  with  a  layer  of  im- 
perfect cartilage  and  lubricated  by  a  serous  secretion 
resembling  synovial  fluid. 

3.  In  true  non-U7iion  the  ends  of  the  bone  are 
quite  separate,  there  being  an  entire  absence  of  any 
unitinsc  material. 

The  causes  which  may  give  rise  to  these  conditions 
are  both  constitutional  and  local. 

The  constitutional  include  all  those  conditions 
wliich,  by  inducing  a  low  state  of  health,  interfere 
with  the  healthy  nutrition  of  the  tissues,  and,  conse- 
quently, with  the  process  of  repair,  e.g.  various  acute 
affections,  such  as  fevers,  syphilis,  the  cancerous 
cachexia,  phthisis,  scurvy,  chronic  kidney  disease,  etc. 
Old  age,  pregnancy,  and  lactation  are  sometimes  said 
to  interfere  with  union,  but  as  a  rule  their  influence  is 
very  slight. 

The  local  causes  are  also  various. 

Mobility  of  the  fragments  is  probably  the  most 
common.     This  may  be  due  to  the  splints  or  bandages 


24  A  Fan  UAL  of  Surgekv. 

being  applied  too  loosely,  or  in  consequence  of  their 
removal  before  repair  is  completely  effected. 

Separation  of  the  fragments  is  another  cause  of 
non-union.  This  may  be  due  to  muscular  action,  as 
in  the  case  of  the  patella,  or  to  interposition  of  a 
portion  of  muscle  or  tendon  between  the  ends  of  the 
bone.  In  cases  of  compound  fracture,  non-union  is 
often  due  to  actual  loss  of  bone,  removed  either  at  the 
time  of  injury,  or  subsequently  for  necrosis.  Inter- 
ference with  the  circulation  of  the  blood  may  also 
prevent  repair  from  taking  place  ;  e.g.  non-union  is 
apt  to  occur  in  cases  where  the  nutrient  artery  of  the 
bone  is  injured  by  the  line  of  fracture  running  through 
it ;  or  where  blood  is  not  freely  supplied  to  both 
fragments,  as  in  fracture  of  the  neck  of  the  humerus 
or  femur ;  or,  again,  in  cases  where  a  congested  and 
oedematous  condition  of  the  limb  is  produced  as  the 
result  of  tight  bandaging,  or  from  extensive  bruising 
of  the  soft  parts  accomjDanied  by  venous  thrombosis. 

The  treatment  is  partly  constitutional,  partly 
local.  As  regards  the  former,  attention  should  be 
paid  to  the  general  health,  and  any  constitutional  con- 
dition which  is  present  should  be  treated  on  ordinaiy 
princij^les. 

As  regards  local  treatment,  measures  similar  to 
those  recommended  in  the  case  of  delayed  union  (page 
22)  should  be  tried,  and  if  they  fail,  more  vigorous 
ones  should  be  adopted,  the  object  being  to  set  up  a 
more  active  inflammation  at  the  seat  of  injury. 

This  may  be  attempted  in  various  ways  ;  e.g.  by 
the  introduction  of  acupuncture  needles,  or  of  a  seton 
between  the  ends  of  the  bone,  by  the  subcutaneous 
division  with  a  tenotome  of  the  fibrous  tissue  which 
unites  them  ;  by  electro-puncture  ;  or  by  the  injection 
of  some  stimulating  liquid  in  the  neighbourhood  of 
the  fracture. 

If  these  methods  prove  unsuccessful,  the  ends  of 


Mal-Union  of  Fracture.  25 

the  bone  should  })C  exposed,  and  one  or  other  of  tlie 
following  plans  adopted  :  ivory  pegs  are  driven  into 
holes  bored  in  the  bone  with  a  drill ;  or  the  ends  of  tlie 
bone  are  removed  with  a  saw  (the  periosteum  being  as 
far  as  possible  preserved)  and  the  fragments  then 
brought  together  by  metallic  screws  or  sutures  of  silver 
wire.  The  latter  method,  "  wiring  the  fragments," 
is  commonly  adopted,  and  as  a  rule  with  good  results, 
the  sutures  being  either  removed  after  several  weeks  or 
cut  short  and  left  permanently.  When  non-union  is  due 
to  actual  loss  of  osseous  tissue,  as  in  some  cases  of 
compound  fracture,  attempts  have  been  made  to  fill 
up  the  gap  by  transplanting  bone. 

When  operative  treatment  has  proved  unsuccess- 
ful, and  the  limb  is  useless  and  an  encumbrance  to  the 
patient,  amputation  maybe  indicated,  but  even  under 
these  circumstances,  and  especially  in  the  upper  ex- 
tremity, some  form  of  apparatus  can  often  be  adapted 
to  the  part,  so  that,  though  its  usefulness  is  much 
impaired,  it  will,  nevertheless,  prove  much  more 
serviceable  than  an  artificial  limb. 

Union  \%'itli  deformity. — Union  is  sometimes 
accompanied  by  considerable  deformity,  and  the 
function  of  the  limb  is  in  consequence  seriously  im- 
paired. This  condition,  "vicious  union,"  as  it  is  often 
termed,  may  be  owing  to  restlessness  of  the  patient,  or 
to  unskilful  treatment,  e.g.  imperfect  reduction  of 
the  fracture  ;  impro})er  application  of  splints,  in  conse- 
quence of  which  the  fragments  are  not  kept  in  position 
or  at  rest ;  removal  of  the  splints  before  union  is  com- 
pletely effected  and  subsequent  yielding  of  the  callus, 
etc.  Under  these  circumstances,  union  is  often  ac- 
companied by  considerable  projection  of  one  or  both 
fragments.  Another  form  of  vicious  union  is  seen  in 
cases  when  two  contiguous  bones  become  united  by 
callus  thrown  out  between  them,  e.g.  in  the  fore-arm, 
leg,    or    ribs ;    this  deformity    is,  however,    of   little 


26  Manual  of  Surgery. 

importance  excL'[>t  in  the  fore-arm,  wlien  the  move- 
ments of  2)ronation  and  supination  become  interfered 
with. 

The  treatment  will  depend  on  the  nature  of  the 
deformity  and  the  length  of  time  which  has  elapsed 
since  the  fracture  occurred.  When  there  is  projection 
of  the  fragments  and  the  callus  is  not  yet  firmly 
ossified,  the  deformity  will  often  gradually  disap})ear 
under  firm  pressure  properly  applied  by  well-padded 
splints,  or  the  limb  may  be  forcibly  straightened  at 
once  under  anjEsthesia.  If,  however,  a  considerable 
period  has  elapsed,  and  firm  bony  union  has  taken 
place,  it  will  often  be  necessary  to  refracture  the  limb 
either  by  manual  force,  or  by  the  employment  of  a 
strong  clamp,  known  as  the  osteoclast. 

In  other  cases,  before  the  bone  can  be  straightened, 
it  may  be  necessary  to  divide  it  subcutaneously,  or 
remove  a  w^edge-shaped  piece  of  bone  from  the 
projecting  angle.  The  shai-p  end  of  one  of  the  frag- 
ments, if  projecting  beneath  the  skin,  may  be  treated 
as  an  exostosis  and  sawn  oflT,  but  it  will  usually  be 
found  that,  if  allowed  to  remain,  it  will  wear  down  and 
become  rounded  oflT,  so  that  in  course  of  time  it  will 
often  gradually  disappear  to  a  great  extent.  The 
limb,  after  it  has  been  straightened  by  any  of  these 
methods,  should  be  put  up  again  in  splints  and  treated 
as  a  recent  fracture,  care  being  taken  to  prevent 
any  recurrence  of  the  deformity. 

"Wounds  of  bone  are  closely  comiected  with 
compound  fractures.  It  will,  however,  sometimes 
happen  that  a  kind  of  incised  wound  is  produced,  the 
periosteum  and  a  portion  of  the  thickness  of  a  bone 
being  divided  as  the  result  of  a  blow  with  some  cutting 
instrument.  Punctured  wounds  have  already  been 
referred  to,  and  gun-shot  wounds  are  discussed  in  the 
chapter  on  that  subject  As  the  injury  to  the  bone  is 
always  accompanied   by  an   open  wound,  the  general 


Fractures  of  the  Nose.  27 

treatment  will  be  identical  with  that  of  compound 
fracture. 

Contusions  of  toone  are  of  common  occurrence, 
Leing  often  met  with  in  those  that  are  superficial  and 
exposed  to  external  violence,  e.g.  the  subcutaneous 
surface  of  the  tibia,  vault  of  the  skull,  etc.  The  injury- 
is  often  followed  by  inflammation  of  the  periosteum, 
evidences  of  which  will  be  present,  and  when  the 
process  is  limited,  the  localised  swelling,  which  fre- 
quently results,  is. described  as  a  "traumatic  node." 

In  other  cases,  e.g.  as  a  result  of  a  fall  on  the  hip, 
the  cancellous  tissue  of  the  neck  of  the  femur  may 
become  more  or  less  bruised  or  contused  ;  inflammatory 
changes  of  a  subacute  or  chi'onic  nature  may  subse- 
quently ensue,  occasionally  followed  by  an  interstitial 
absorption  of  the  osseous  tissue,  in  consequence  of 
which  the  limb  may  become  permanently  shortened. 

Special  Fractures. 

THE    FACE. 

Nasal  bones.— Fracture  of  the  nasal  bones  is 
often  produced  as  the  result  of  direct  violence,  e.g.  a 
fall  or  blow  on  the  nose  ;  it  is  in  consequence  usually 
attended  by  bruising  or  laceration  of  the  soft  tissues, 
and  in  many  cases  considerable  swelling,  sometimes 
accompanied  by  emphysema,  speedily  sets  in,  so  that 
unless  seen  soon  after  the  receipt  of  the  injury,  the 
detection  of  the  fracture  may  be  somewhat  dilhcult. 

The  fragments  may  be  displaced  backwards,  or  to 
one  side,  the  bridge  of  the  nose  being  in  consequence 
either  flattened  or  deflected  laterally.  If  the  fracture 
also  involves  the  ?ac/r/'2/maZ  hone  there  may  be  obstruc- 
tion to  the  flow  of  tears,  and  epiphora,  owing  to  injury 
to  the  lachrymal  sac  or  nasal  duct. 

Fracture  through  the  septum  nasi^  or  separation 
from  its  attachment  to  the  vomer,  may  occur  alone,  or 


28  Manual  of  Surgery. 

accompany  a  fracture  of  the  nasal  l)ones  ;  in  some 
cases  the  cartilaginous  septum  is  simply  bent  to  one 
side,  giving  rise  to  a  troublesome  and  characteristic 
deformity. 

Treatment. — When  any  displacement  of  the  frag- 
ments is  present,  an  attempt  should  be  made  to  correct 
it  as  speedily  as  possible,  for  if  allowed  to  remain, 
union  rapidly  takes  place,  and  considerable  difficulty 
will  afterwards  be  experienced  in  treating  the  defor- 
mity. 

This  can  usually  be  effected  by  means  of  an 
ordinary  pair  of  polypus  forceps,  introduced  into  the 
nostril ;  on  using  them  as  a  lever,  or  on  separating 
the  blades,  the  displaced  fragments  can  usually,  with  a 
little  manipulation,  be  guided  back  into  the  normal 
position,  especially  if  the  patient  is  ansesthetised. 
When  once  replaced,  they  will  often  remain  so  ;  if, 
however,  there  is  any  tendency  for  the  displacement 
to  return,  it  can  sometimes  be  prevented  by  the 
patient  wearing  in  the  nostril  a  short  piece  of  gum- 
elastic  catheter,  or  some  form  of  plug. 

When  the  nose  is  bent  to  one  side,  it  may  be 
necessary  to  make  lateral  pressure  from  without,  and 
for  this  purpose  Adams's  "  nose  truss,"  consisting  of  a 
pad  adjusted  by  cog  wheels  and  attached  to  a  steed 
band  wliicli  passes  round  the  head,  will  often  be  found 
useful. 

When  the  septum  is  deflected,  it  can  usually  be 
straiglitened  under  anaesthesia,  by  means  of  Adams's 
forceps,  a  pair  of  strong  forceps  with  flat  parallel 
blades,  and  at  the  same  time  the  nasal  bones,  if 
depi-essed,  can  also  be  raised.  As  there  is  generally  a 
tendency  for  the  deflection  to  recur,  the  patient  should 
for  a  time  wear  some  apparatus  to  retain  the  septum 
in  position,  e.g.  Adams's  steel  screw  compressor, 
or  an  ivory  plug. 

Upper  jiiw    siiid  malar  bone. — Fracture  of 


Fractures  of  the  Jaw.  29 

the  upper  jaw  is  sometimes  met  with  as  the  result  of 
direct  violence,  its  alveolar  process  being  the  part  more 
commonly  involved  ;  less  frequently,  the  fracture  takes 
place  through  the  body  of  the  jaw  or  one  of  the  other 
processes,  and  it  may  also  involve  the  malar  hone  and 
zygomatic  arch. 

The  fracture,  which  is  often  compound  and  accom- 
panied by  bruising  and  swelling  of  the  cheek,  may  or 
may  not  be  attended  by  displacement  of  the  fragments  ; 
when  the  anterior  wall  of  the  antrum  is  driven  in, 
considerable  deformity  is  often  produced,  and  when 
the  alveolus  is  involved,  there  will  be  loosening  and 
irregularity  in  the  line  of  the  teeth. 

Various  complications  may  attend  this  fracture  ; 
e.g.  emphysema ;  severe  haemorrhage  from  a  wound  of 
the  internal  maxillary  artery ;  loss  of  sensation  in  the 
cheek  from  injury  to  the  infra-orbital  nerve ;  in  cases 
of  compound  fracture  involving  the  antrum,  a  sinus 
often  remains  which  is  slow  in  healino:. 

Treatment. — "When  any  displacement  of  the  frag- 
ments is  present,  an  attempt  should  be  made  to  correct 
it  as  soon  as  possible  ;  the  depressed  bone  can  often 
be  raised  from  the  mouth,  or,  if  this  is  not  possible, 
by  means  of  an  elevator  introduced  through  a  small 
opening  in  the  cheek. 

When  the  alveolar  process  is  involved,  the  frag- 
ments can  usually  be  kept  in  position  by  one  or  other 
of  the  methods  of  treatment  mentioned  in  the  case  of  the 
lower  jaw  ;  a  jaw  bandage  should  afterwards  be  applied 
so  as  to  prevent,  as  far  as  possible,  any  movement  of 
the  part,  and  the  patient  fed  on  liquid  food  for  several 
weeks. 

LiOw^er  jau% — Fractures  of  the  lower  jaw  are 
almost  always  compound,  sometimes  from  external 
wound,  but  more  frequently  from  laceration  of  the 
gum  by  the  broken  fragments.  Any  part  of  the  bone 
may  be  broken,  the  commonest  situation  being  tlirough 


30  Manual  of  Surgery. 

the  body,  at  that  spot  where  it  is  specially  weakened 
by  the  mental  foramen  and  the  deep  socket  for  the 
canine  tooth  ;  fracture  through  the  symphysis  is  rare 
owing  to  the  strength  of  bone  at  this  point. 

Body. — In  fracture  through  the  body  the  symi)- 
toms  are  usually  well  marked,  especially  when,  as  is 
often  the  case,  the  bone  is  broken  on  both  sides  of  the 
symphysis,  for  the  central  portion  is  then  drawn  down 
by  the  muscles  attached  to  the  hyoid  bone.  There  is 
mobility  of  the  fragments,  with  crepitus,  loosening 
and  irregularity  in  the  line  of  the  teeth,  dribbling  of 
the  saliva  from  the  mouth,  and  impairment  of  speech. 

When  the  fracture  is  compound,  there  is  also 
laceration  of  and  bleeding  from  the  gums  ;  under  these 
circumstances  suppuration  generally  results,  and  the 
discharge  making  its  way  into  the  mouth  and  mingling 
with  the  saliva  gives  to  the  breath  an  offensive  odour ; 
in  cases  where  an  abscess  forms  at  the  seat  of  injury, 
necrosis  of  a  portion  of  the  jaw  frequently  results. 
The  inferior  dental  nerve  visually  escapes,  but  if  it 
happens  to  be  torn  across  by  the  fracture,  there  will 
be  loss  of  sensation  in  the  lip  on  the  corresponding  side. 

Angle  or  lower  2:>art  of  ramus. — In  this  situation 
the  displacement  of  the  fragments  is  usually  slight, 
for  the  muscles  on  either  side  (masseter  and  internal 
pterygoid)  maintain  them  in  position. 

Keck. — In  fracture  through  the  neck  of  the  jaw, 
the  condyle  is  drawn  inwards  and  forwaids  by  the 
external  pterygoid  ;  crepitus  is  produced  and  pain  is 
experienced  upon  attempting  to  open  the  mouth. 

Goronoid  process. — The  fractured  coronoid  process 
is  drawn  upwards  and  backwards  by  the  temporal 
muscle,  so  that  it  produces  an  undue  prominence  in 
the  temporal  fossa. 

Treatment. — In  cases  where  there  is  not  much  dis- 
placement of  the  fragments,  tlrey  can  often  be  kept  in 
position  by  a  four-tailed  bandage,  or  by  la  guttapercha 


Fractures  of  the  Jaw. 


31 


Fig.  2.  —  Guttapercha  Splint  for 
Jaw.  (From  Pick's  "  Fractures 
and  Dislocations.") 


splint  (Fig.  2),  moulded  to  the  jaw,  and  fixed  by  a 
similar  bandage.  Any  teeth  which  are  com])letely 
loose  and  lie  between  the  fragments  should  be  re- 
moved, for  their  presence  interferes  with  the  process 
of  repair ;  those  which  are  only  partially  loose  should, 
if  healthy,  be  allowed  to  remain,  for  they  will,  as  a 
rule,  soon  become  firmly 
adherent.  When  -difii- 
culty  is  experienced  in 
keeping  the  fragments  in 
position,  as  often  happens 
when  the  fracture  is 
compound,  other  means 
may  be  required. 

Ligaturing  the  teeth, 
i.e.  bindinof  tofjether  those 
which  lie  on  either  side 
of  the  fracture,  with  wire  or  silk,  is  sometimes 
adopted,  but  has  this  disadvantage,  that  it  tends  to 
loosen  the  teeth,  which  are  often  already  somewhat 
loose  in  their  sockets.  The  ligature  is  also  very  liable 
to  slip,  and  in  many  cases,  e.g.  when  the  teeth  are 
absent  or  carious,  it  cannot  be  applied. 

The  fragments  may  be  wired  together,  as  recom- 
mended by  Thomas,  by  means  of  sutures  of  silver 
wire,  which  are  passed  through  openings  drilled  in 
the  bone  on  each  side  of  the  fracture  (Fig.  3),  or 
through  the  bone  on  one  side  and  between  the  teeth 
on  the  other  ;  as  the  wire,  if  tied  or  fastened  with  a 
cross  twist  in  the  ordinary  way,  soon  becomes  loose,  it 
is  twisted  with  a  key  in  three  or  four  coils,  which  can 
be  tightened  up  from  time  to  time  as  they  become 
slackened. 

Various  forms  of  interdental  splints  are  also  em- 
ployed, e.g.  moulds  of  guttaperclia,  vulcanite  or  metal 
caps,  etc.,  which  fit  on  to  the  teeth  for  some  distance 
on  either  side  of  the  fracture. 


32 


Manual  of  Surgery, 


INEoon's  interdental  splint  consists  of  two  parts,  an 
external  splint  adapted  to  the  and  chin  attached  by 
rods  to  a  metal  cap,  which  fits  the  teeth  of  the  frac- 
tured jaw. 

Hammond's  wire  splint  is  made  of  a  framework  of 
iron  wire,  adjusted  so  as  to  encircle,  on  a  level  with 
their  necks,  all  or  several  of  the  teeth  on  either  side 
of  the  fracture. 

As  it  is  important  that  the  fracture,  should,  as  far 


Fig.  3.— Thomas's  Drill  and  Suture  for  Fractured  Jaw. 

as  possible,  be  kept  completely  at  rest,  talking  should 
be  prohibited,  and  the  patient  fed  on  liquids,  or  on 
soft  food  which  requires  no  mastication.  The  mouth 
should,  especially  in  cases  of  compound  fracture,  be 
frequently  washed  out  with  a  solution  of  Condy's 
fluid,  or  some  other  disinfectant. 

Union,  as  a  rule,  takes  place  in  from  three  to  five 
weeks,  though  the  process  will  be  somewhat  retarded 
if  suppuration  takes  place,  or  if  necrosis  results. 

The  Clavicle. 

The  clavicle  may  be  fractured  in  any  part  of  its 
course,  more  commonly  about  its  middle,  less  frequently 


Fractures  if  the  Clavicle.  33 

at  either  its  sternal  or  acromial  extremity.  Thouch 
fracture  may  be  produced  as  tlie  result  of  direct  apj)li- 
cation  of  force,  e.g.  a  severe  blow,  or  even  of  muscular 
action,  e.g.  a  sudden  and  forcible  swing  of  the  arm, 
it  is  far  more  frequently  tlie  result  of  indirect  vio- 
lence, e.g.  a  fall  on  to  the  shoulder  or  hand  wlien 
tlie  arm  is  extended. 

Sianfr. — In  fracture  thi-ough  the  shaft  tlie  bone 
usually  gives  way  at  its  weakest  point,  viz.  about  its 
centre,  or  a  little  external  to  it,  just  at  the  junction 
of  the  two  curves.  The  fracture,  whicli  is  of  very 
common  occurrence  in  young  subjects,  is  often  of  the 
incomplete  or  "  greenstick "  nature,  the  bone  being 
bent,  or  only  partially  broken,  the  periosteum  fre- 
quently remaining  nntorn  (Fig.  1). 

When  complete,  the  line  of  fracture  is  sometimes 
transverse,  but  more  commonly  and  especially  when 
due  to  indirect  violence,  it  is  ol)lique  ;  under  these  cir- 
cumstances the  amount  of  displacement  is  often  con- 
si(k^rable.  The  inner  fragment  usually  remains  un- 
afiected,  being  retained  in  its  place  by  the  antagonistic 
action  of  the  sterno-mastoid  above,  and  the  pectoralis 
major  and  subclavius  muscles,  and  rhomboid  ligament 
below ;  though,  in  many  cases,  it  appears  to  be  dis- 
placed forwards,  this  is  in  reality  due  to  the  dej^ression 
of  the  inner  end  of  the  outer  fragment  backwards  and 
behind  it. 

The  outer  fragment,  owing  to  the  weight  of  the 
arm,  which  drags  upon  it,  is  usually  drawn  downwards, 
while  by  the  action  of  the  muscles  passing  to  it  from 
the  chest  it  is  drawn  somewhat  inwards  and  forwards  ; 
lience,  its  outer  or  acromial  end  with  the  shoulder  is 
dis])laced  downwards,  inwards,  and  forwards,  while  its 
inner  or  fractured  end  is  drawn  inwards  and  back- 
wards, so  that  it  lies  behind  and  usually  beneath  the 
fractured  end  of  the  inner  fragment ;  less  frequently  it 
is  found  above,  and  in  rare  cases  it  may  lie  anterior  to  it. 
D— 21 


34  Manual  of  Surgery. 

The  symptoms  are  as  follows :  Flattening  and 
lowering  of  the  shoulder,  which  is  also  drawn  forwards 
and  inwards,  being  approximated  to  the  middle  line; 
pain  at  the  seat  of  injury  ;  impaired  movement  of  the 
arm  ;  inclination  of  the  head  and  neck  to  the  affected 
side  ;  the  elbow  is  often  supported  by  the  opposite  hand 
to  take  off  the  wei^-ht  of  the  limb ;  if  the  finger  is  laid 
over  the  seat  of  fracture,  crepitus  can  generally  be 
detected  on  raising  and  rotating  the  shoulder,  and  at 
the  same  time  pain  will  be  produced  ;  the  prominence 
formed  by  the  fractured  end  of  the  inner  fragment  will 
generally  be  plainly  perceptible  beneath  the  skin  ;  in 
cases  of  transverse  fracture,  where  the  displacement 
of  the  fragments  is  often  very  slight,  there  may  be 
an  entire  absence  of  any  deformity. 

Sternal  end. — Fracture  of  the  sternal  end  of  the 
clavicle,  either  internal  or  external  to  the  attachment 
of  the  rhomboid  ligament,  is  an  injury  of  rare  occur- 
rence ;  in  the  latter  case  the  displacement  is  often 
considerable,  the  outer  fragment  being  drawn  down- 
wards and  forwards ;  in  the  former  case,  which  is 
much  less  common,  there  is  not,  as  a  rule,  any  marked 
displacement  of  the  fragments. 

Aei'ossaml  encl. — Fracture  of  the  acromial  end  is 
of  mucli  more  frequent  occurrence,  and  two  varieties 
are  met  with,  according  as  the  bone  is  broken  between 
or  external  to  the  conoid  and  trapezoid  ligaments. 
When  the  fracture  is  between  the  ligaments  there  is 
little,  if  any,  displacement  of  the  fragments  ;  on  ro- 
tating the  shoulder  crepitus  is  produced,  and  perhaps 
slight  irregularity  will  be  felt  at  the  seat  of  injury. 

When  the  fracture  is  external  to  the  ligamonts 
there  is  a  marked  displacement  of  the  outer  fragment, 
its  articular  surface  being  turned  forwards  and  inwards, 
with  a  sliirht  inclination  downwards,  so  that  it  lies 
nearly  at  a  right  angle  with  the  rest  of  the  bone,  the 
position  of  wliich  Ls  not  materially  altered. 


Fractures  of  the  Clavicle.  35 

Separation  of  tlic  epiphysis  of  the  clavicle,  a 
thin  plate  of  bone  at  its  sternal  extremity,  is  a  rare 
injury. 

Fractures  of  the  cla\dcle,  when  the  result  of  direct 
violence,  may  be  compound  or  comminuted  ;  in  these 
injuries,  which  are,  however,  of  rare  occurrence,  the 
neighbouring  large  vessels,  e.g.  jugular  or  subclaAian 
veins,  etc.,  are  liable  to  be  wounded.  A  simjJe  frac- 
ture is  occasionally  followed  by  partial  f)araiysis  of  the 
arm,  the  result  probably  of  compression  or  laceration  of 
the  cords  of  the  brachial  plexus  by  the  displaced  frag- 
ments. Owing  to  the  difficulty  of  keeping  the  frac- 
ture in  a  state  of  complete  rest,  union  is  invariably 
attended  by  the  formation  of  provisional  callus,  and 
in  cases  where  treatment  has  been  neglected,  or  there 
is  much  displacement  of  the  fragments,  this  is  often 
excessive  in  amount,  giving  rise  to  a  considerable 
swelling  surrounding  the  bone  at  the  seat  of 
injury. 

Treatment. — In  the  treatment  of  the  common  form 
of  fracture  through  the  shaft  there  are  three  main 
indications  to  be  carried  out,  viz.  to  raise  the  shoulder 
with  the  outer  fragment,  and  at  the  same  time  to 
draw  it  backwards  and  outwards. 

To  raise  the  shoulder,  the  arm  should  be  supported 
in  :i  sling  which  reaches  well  under  the  elbow,  or  by 
strapping  or  bandages  which  pass  beneath  the  elbow 
and  o^er  the  opposite  shoulder. 

To  draw  the  shoulder  outwards,  a  thick,  wedge- 
shaped  pad,  with  its  broad  end  upwards,  should  be 
placed  high  up  in  the  axilla,  where  it  is  kept  in  posi- 
tion by  a  strap  which  passes  over  the  opposite 
shoulder.  The  arm  being  then  bandaged  to  the  side, 
the  pad  acts  as  a  fulcnim,  and  the  humerus  as  a  lever  ; 
the  result  is  that  the  shoulder  and  outer  fracrment  are 
drawn  forcibly  outwards.  In  applying  the  pad,  cai-e 
must  be  taken  that  too  much  pressure  is  not  made 


36 


Manual  of  Surgery. 


upon  the  axillary  vessels  and  nerves,  or  else  the  arm 
will  become  swollen,  and  either  numb  or  painful. 

To  carry  the  shoulder  backwards,  several  different 
plans  may  be  adopted.  The  elbow  may  be  carried 
forwards,  and  the  hand  raised  towards  the  opposite 
shoulder,  so  that  the  humerus  m:iy  l)car  across  the 
pad,  and  its  upper  end  along  witli  tlie  shoulder  be 
forced  backwards  ;  or  a  figure  of  8  bandage  may 
be  applied  to  the  shoulders  and  tied  behind. 

In  order  to  prevent  the  1)andages  from  slipping, 
the  turns  may  be  stitched  together,  or  stifTened  Avith 
plaster  of  Paris  or  starch.  If  there  is  any  tendency 
to  swelling  of  the  arm,  it  should  first  be  bandaged 
from  the  fingers  up  to  the  axilla. 

Sayre's  method  of  treating  this  fracture  is  as  fol- 
lows :    A  loop  at  the  end  of  a  broad  band  of  adhesive 

plaister  is  passed  roinid  the 
upper  part  of  the  arm,  and 
the  elbow  having  l»een 
drawn  backwards,  the 
strapping  is  carried  trans- 
versely behind  the  back 
and  round  the  chest.  A 
second  piece  is  then  carried 
obliquely  across  the  body, 
viz.  over  the  sound 
shoulder,  and  beneath  the 
elbow  on  the  injured  side, 
a  slit  beiug  cut  in  it  to 
receive  the  elbow  and 
prevent  it  from  slipping. 
By  the  first  stiip  the 
shoulder  is  drawn  back- 
wards and  outwards,  while  by  the  second  it  is  raised 
(Fig.  4). 

Ellis's  method  consists  in  the  application  of  an 
axillary    splint   or   crutch,    which    is    maintained    in 


Fi 


4.-  Sayre's  Mct.liOfl  for  Frac- 
tured Clavicle. 


Fractures  of  the  Clavicle. 


37 


position  by  two  straps,  one  passing  over  the  opposite 
shoulder,  the  other  round  the  chest ;  the  hitter  also 
fixes  the  upper  arm  and  keeps  it  to  the  side ;  the 
fore-arm  is  supported  in  an  ordinary  sling  (Fig.  5). 

If  a  patient  will  submit  to  conriiiement  to  bed,  it 
will  generally  be 
found  that  the  de- 
formity more  or  less 
completely  disap[)ears 
in  the  recumbent  pos- 
ture, for  the  weight 
of  the  limb  being  re- 
moved, the  dLsplace- 
ment  downwards  is 
prevented;  at  the  same 
time,  the  shoulder 
falling  back  and  carry- 
ing with  it  the  outer 
fragment,  the  dis- 
placement forwards 
and  inwards  is  also 
counteracted  ;  the 
consequence  is  that 
the  ends  of  the  bone 

usually  fall  well  into  position.  Mr.  Bryant  recom- 
mends that  an  attempt  should  be  made  to  imitate 
what  takes  place  when  the  patient  is  in  the  supine 
position,  by  placing  a  pad  over  the  blade  of  the 
scapula  below  its  spine,  and  then  binding  the  bone 
firmly  to  the  thorax  by  broad  strips  of  strapping, 
which  obliquely  encircle  the  chest  on  the  affected  side 
and  reach  from  the  spine  to  the  sternum.  The  arm 
should  also  be  supported  in  a  sling  and  the  hand  drawn 
upwards  towards  the  op]iosite  shoulder. 

In  cases  where  no  displacement  of  the  fragments 
is  present,  as  may  occasionally  happen  in  fracture 
through    the    shaft,    or    in  fracture    internal    to    the 


Fig.  5.— Ellis'  Method  for  Fi-actiiroa 
Clavicle.  (From  Pick's  "  Fractures 
and  Dislocatious.") 


38  Manual  of  Surgery. 

rhomboid,  or  between  the  conoid  and  trapezoid  liga- 
ments, all  that  is  often  necessary  is  to  keep  the  arm 
fixed  to  the  side  and  supjiorted  in  a  sling. 

In  fracture  external  to  the  conoid  and  trapezoid 
ligaments,  in  addition  to  a  thick  pad  in  the  axilla,  it 
will  often  be  found  necessary  to  apply  a  figure  of  8 
bandage  behind  the  shoulders,  in  order  to  overcome 
the  displacement  forwards  of  the  shoulder  with  the 
outer  fragment. 

Union  is,  as  a  rule,  effected  in  from  three  to  four 
weeks. 

The  Scapula. 

Fracture  of  the  scapula  may  involve  its  body,  neck, 
acromion,  or  coracoid  process. 

Botly. — Fracture  through  the  body  is  usually  the 
result  of  direct  violence  and  is  often  associated  with 
injury  to  the  subjacent  ribs.  It  is  not,  however,  an 
accident  of  very  common  occurrence,  for  the  thick 
layers  of  muscles  which  lie  both  over  and  beneath  the 
bone  form,  as  it  were,  soft  pads  which  serve  to  protect 
it.  The  fracture  usually  affects  the  infraspinous  por- 
tion of  the  bone,  running  across  it  in  an  oblique  or 
transverse  direction  ;  or  it  may  extend  in  a  vertical 
direction  right  through  the  spine. 

Abnormal  mobility  and  crepitus  can  generally  be 
detected  on  moving  the  shoulder  and  uj^per  part  of  the 
scapula  with  one  hand,  while  the  other  is  laid  upon, 
or  made  to  fix,  the  lower  portion  of  the  lx)ne.  Jn 
iDuscular  subjects,  and  when  the  fracture  involves  thy 
iiifraspinuiis  fossii^  there  will  (jfteii  be  slight,  if  any, 
displacement  of  tlie  fragments ;  wlien,  however,  it 
1  uus  across  the  spine,  some  irregularity  in  its  course 
can  usually  be  detected. 

Acroiiiiou.  —  Owing  to  its  exposed  position, 
forming  as  it  does  the  tip  of  the  shoulder,  the  acro- 
mion  is   more    frequently    fractured   than   any   other 


Fractures  of  the  Scapula.  39 

portion  of  the  bone,  and  usually  as  the  result  of  direct 
violence- 
Abnormal  mobility  and  crertitus  can  be  readily 
detected  on  i-aising  and  rotating  the  shoulder  ;  more  or 
less  deformity  is  present,  the  shoulder  becoming  flat- 
tened and  somewhat  depressed.  On  running  the  finger 
along  the  acromion,  an  irregularity  can  be  felt  at  the 
seat  of  fracture ;  pain  is  present  and  the  movements 
of  the  arm  are  interfered  with. 

There  are  two  affections  which  simulate  fracture  of 
the  acromion,  viz.  non-union  of  the  acromial  epiphysis, 
a  condition  which  sometimes  exists,  and  certain  cases 
of  rheumatic  arthritis  of  the  shoulder  joint,  in  which, 
osteophytic  deposits  about  the  acromion  are  found  lying 
loose  and  movable  beneath  the  skin  ;  under  these  cir- 
cumstances, crepitation  can  usually  be  detected. 

Coracoid  pi'ocess. — Fracture  of  this  process  is 
rare,  lying  as  it  does  in  a  hollow  protected  by  the  cla- 
vicle above,  the  thorax  internally,  and  the  head  of  the 
humerus  externally  ;  it  is  usually  the  result  of  direct 
violence.  The  only  symptoms  present  will  be  mobility 
of  the  broken  fragment,  with  pain  and  crepitus  on 
manipulation ;  if  the  coraco-clavicular  ligament  is 
riTptured,  the  fractured  ])rocess  may  be  drawn  down- 
wards by  the  action  of  the  biceps  and  coraco-brachialis 
muscles. 

Necli. — Fracture  through  the  neck  of  the  scapula 
is  so  rare  that  its  occurrence  has  been  doubted  ;  two 
varieties  have,  however,  been  described  according  as 
the  anatomical  or  surcrical  neck  of  the  bone  is  in- 
volved. 

In  fracture  through  the  siirjfical  ueck  the  line 
of  fracture  runs  across  the  constricted  portion  of  the 
bone  opposite  the  notch  in  the  superior  costa,  the  cora- 
coid process  being  included  in  the  detached  piece.  If 
the  coraco-clavicular  and  coraco-acromial  ligaments  are 
not  ruptured,  there  may  be  very  little  deformity  ;  if, 


40  Manual  of  Surgery, 

however,  tlioy  give  way,  the  broken  fragment  along 
with  the  arm  is  displaced  downwards,  so  that  the 
symptoms  are  very  similar  to  those  of  subglenoid  dis- 
location of  the  humerus  ;  viz.  there  is  flattening  and 
lowering  of  the  shoulder,  with  prominence  of  the  acro- 
mion and  a  depression  beneath  it;  the  arm  is  lengthened 
and  somewhat  separated  from  the  side ;  the  head  of 
the  humerus  can  be  felt  in  the  axilla. 

The  injury  differs,  however,  from  dislocation  in 
the  following  points  ;  the  coracoid  process  is  displaced 
and  moves  with  the  arm,  which  is  abnormally  mobile ; 
crepitus  can  readily  be  detected  ;  on  raising  the  arm, 
the  deformity  disappears,  but  at  once  returns  when  the 
ai-m  is  allowed  to  drop  ;  an  irregular  mass  of  bone, 
formed  by  the  neck  of  the  scapula,  can  be  felt  in  the 
axilla,  very  diifereut  to  the  smooth,  rounded  promi- 
nence formed  by  the  head  of  the  humerus,  which  alone 
is  present  in  cases  of  dislocation. 

In  fracture  through  the  aMSJtoiiiical  iicek  the 
glenoid  process  only  is  separated  from  the  rest  of  the 
bone ;  the  symptoms  will  be  very  similar,  except  that 
the  coracoid  process  preserves  its  normal  relation  and 
does  not  move  with  the  arm. 

Treatment. — In  fracture  through  the  body  the 
fragments  should  be  brought  into  position,  and  then 
maintained  so  by  a  })ad  of  lint,  secured  by  strips  of 
strapping  which  encircle  half  the  chest.  The  arm 
should  be  fixed  to  the  side  by  a  body  bandage  and  the 
elbow  supported  in  a  sling. 

In  fracture  through  the  acromion  the  elbow  should 
be  well  supported  by  a  sling,  or  by  a  broad  strip  of 
strapping  (as  in  the  case  of  the  clavicle)  which  passes 
beneath  it  and  over  the  opposite  shoulder.  A  pad 
should  be  fixed  in  the  axilla  and  the  arm  bandaijed  to 
the  side. 

In  fracture  through  the  neck  a  similar  plan  of 
treatment  is  required. 


Fractures  of  the  Humerus.  41 

In  fi-acture  througli  the  coracoid  process  the  fore- 
arm should  be  flexed  and  carried  across  the  chest,  so 
that  the  hand  rests  on  the  opposite  shoulder,  in  order 
to  relax  the  biceps  and  coraco-brachialis  muscles  ;  the 
elbow  should  also  be  supported  in  a  sling. 

The  Humerus. 

Fractures  of  the  humerus  may  be  divided  into  fi-ac- 
tures  of  the  upper  extremity,  shaft,  and  lower  ex- 
tremity. 

Upper  exlreiuity.— Fractures  of  the  upper  extre- 
mity may  be  subdivided  into  fractures  of  the  anato- 
mical and  surgical  neck,  separation  of  the  great 
tuberosity  and  of  the  upper  epiphysis.  They  are 
usually  produced  by  direct  violence,  e.g.  a  fall  or  blow 
upon  the  shoulder  ;  less  frequently  they  follow  falls 
upon  the  hand  or  elbow. 

AnatOESiicRl  neck. — Fracture  througli  the  ana- 
tomical neck,  i.e.  above  the  tuberosities  and  within  the 
capsule  of  the  joint,  is  not  of  common  occurrence  ;  it 
may  be  either  impacted  or  non-impacted. 

In  the  impacted  form  the  small  upper  fragment  is 
usually  driven  into  the  wide  surface  of  cancellous 
tissue  at  the  upper  end  of  the  lower  one. 

The  symptoms  are  as  follows :  the  axis  of  the 
humerus  is  altered,  being  directed  somewhat  inwards 
towards  the  coracoid  process,  and  the  ell)ow  being 
slightly  separated  from  the  side  ;  the  arm  is  shortened 
and  the  shoulder  somewhat  flattened ;  the  acromion 
is  more  prominent  than  usual,  and  there  is  a  slight 
depression  beneath  it ;  the  head  of  the  himierus  can 
be  felt  in  the  glenoid  cavity,  and  in  many  instances 
some  alteration  in  its  shape  can  be  detected  ;  crepitus 
is  absent,  unless  the  impaction  is  forcibly  broken 
down.  There  is  loss  of  power,  with  pain,  stiffness, 
and  swelling  about  the  shoulder. 

In    the    non  -  impacted    form    less    deformity    is 


42  Manual  of  Surgery. 

generally  present ;  a  slight  projection  can  be  felt  on 
the  inner  aspect  of  the  joint,  caused  by  the  upper  end 
of  the  lower  fragment ;  crepitus  can  be  detected  on 
rotating  the  arm,  which  is  sliglitly  shortened.  It 
might  be  expected  that  the  head  of  the  bone,  being 
severed  from  all  its  connections,  and  thereby  depiived 
of  its  vascular  supply,  would  necrose,  but  this  result 
very  rarely  takes  j)lace,  fibrous  or  even  osseous  union 
being  usually  effected.  This  is  probaljly  owing  to  the 
fact  that  its  separation  is  often  not  complete,  its 
vitality  being  maintained  through  the  medium  of 
portions  of  the  capsule  which  remain  attached  to  it. 
When  osseous  union  takes  place  the  callus  is  mainly 
thrown  out  by  the  lower  fragment.  When  the  union 
is  merely  fibrous,  considerable  atrophy  of  the  head  of 
the  bone  is  often  produced. 

Treatment. — In  impacted  fracture  all  that  is 
required  is  to  keep  the  part  at  rest,  by  bandaging  the 
arm  to  the  side  and  supporting  the  elbow  in  a  sling. 
Care  should  be  taken  not  to  break  down  the  impaction 
by  the  employment  of  any  force.  If  the  soft  parts 
about  the  shoulder  are  bruised  and  swollen,  some 
evaporating  lotion  should  be  applied. 

In  non-impacted  fracture  it  is,  in  addition,  some- 
times necessary  to  fix  a  small  pad  in  the  axilla,  and  fit 
a  guttapercha  or  felt  cap  to  the  shoulder,  so  as  to  keep 
the  parts  in  apposition  and  completely  at  rest. 

Surreal  ueck. — Fracture  through  the  surgical 
neck  is  the  variety  most  commonly  met  with  about  the 
upper  end  of  the  liumerus,  the  bone  being  usually 
broken  below  the  tuberosities  and  above  the  insertion 
of  the  pectoralis  major  and  latissimus  dorsi  ;  the 
fracture  may  be  either  impacted  or  non-impacted. 

In  the  no7i-impacted^  the  more  common  variety, 
there  is  considerable  displacement  of  the  fragments. 

The  upper  fragment  is  rotated  outwards,  and 
slightly  elevated  under  the  coraco-acromial  ligament 


Fractures  of  the  Humerus.  43 

by  the  muscles  inserted  into  the  two  tuberosities.  The 
lower  fragment  is  drawn  forwards,  upwards,  and 
inwards  beneath  the  coracoid  process,  by  the  muscles 
passing  from  the  trunk  to  the  arm,  and  by  the  flexors 
of  the  arm ;  at  the  same  time  the  lower  end  of  the 
shaft  Ls  thrown  obliquely  outwards  from  the  side  by  the 
action  of  the  deltoid 

The  symptoms  are  as  follows  :  the  lower  fragment 
forms  a  distinct  prominence  beneath  the  coracoid 
process,  most  marked  when  the  elbow  is  raised  ;  the 
head  of  the  bone  can  be  felt  in  the  glenoid  ca\"ityj 
consequently  there  is  no  hollow  immediately  below  the 
acromion,  though  a  slight  depression  is  often  present  a 
little  lower  down,  viz.  just  below  the  end  of  the  upper 
fragment ;  the  axis  of  the  limb  is  altered,  being 
directed  upwards  and  inwards  towards  the  coracoid 
process  ;  cre})itus  can  be  detected  on  extending  and 
rotating  the  limb  ;  the  arm  is  shortened  and  abnormally 
mobile  ;  o^^dng  to  irritation  of  the  branches  of  the 
brachial  plexus  by  the  lower  fi-agment,  2>ain  is  often 
present,  shooting  down  the  arm. 

In  the  impacted  form  the  lower  fragment  is 
usually  driven  into  the  upper.  The  symptoms  are 
chiefly  of  a  negative  character,  the  usual  signs  of 
fracture  being  absent  ;  slight  shortening  is  present, 
with  impaired  movement,  deformity,  and  alteration  in 
the  axis  of  the  limb ;  crepitus  is  absent  unless  the 
impaction  is  broken  down.  The  circumflex  nerve, 
owing  to  its  close  relationship  to  the  neck  of  the 
humerus,  is  liable  to  be  wounded  at  the  time  of 
fracture,  or  it  may  afterwards  become  included  in  the 
callus  by  which  repair  is  effected  ;  under  these  cir- 
cumstances, paralysis  of  the  deltoid,  followed  by 
atrophy,  is  liable  to  occur. 

Treatment. — In  impacted  fracture  the  treatment 
is  the  same  as  in  the  case  of  the  anatomical  neck. 

In     non-impacted    fracture    there    is    the    triple 


44 


Manual  of  Surgery. 


displacement  of  the  lower  fragment  to  be  remedied  ; 
the  displacement  inwards  may  be  counteracted  by 
placing  a  thick  pad  in  the  axilla  and  bandaging  the 
elbow  to  the  side ;  the  displacement  forwards  by 
bandaging  the  elbow  to  the  side  of  the  chest  in  front 

of  the  lateral  median  line, 
so  as  to  throw  backward 
the  upper  end  of  the  shaft ; 
the  displacement  upwards 
by  siip})orting  the  hand 
only  (not  the  elbow)  in  a 
sling,  so  that  the  weight 
of  the  arm  may  act  on  the 
lower  fragment  and  di-ag  it 
down  (Fig.  6).  To  ensure 
the  part  being  kept  com- 
}>letely  at  rest,  a  gutta- 
p<;rcha  or  felt  cap  may  in 
addition  be  fitted  to  the 
shoulder,  and  if  there  is  any 
tendency  to  swelling  of  the 
lindj,  it  should  be  bandaged 
upwards  from  the  fingers. 

In  fractures  of  the  neck 
of  the  humerus,  union  takes 
place  in  four  to  five  weeks,  when  passive  movement 
should  be  begun  ;  in  the  im})acted  forms  the  patient 
should  be  warned  of  the  stifihess  and  deformity  which 
will  be  permanent. 

8i*i>ai'sUion  of  tlio  great  tuberosity.— This 
injury  nuiy  occur  alcdn-,  but  more  commonly  in  connec- 
tion with  a  dislocation  forwards  of  the  humerus  ;  under 
these  circumstances  the  detached  portion  of  bone  is 
drawn  backwards  by  the  muscles  inserted  into  it,  so 
that  it  lies  under  or  external  to  the  acromion  process, 
wldle  the  head  of  the  humerus  is  drawn  forwards 
beneath  the  coracoid  process. 


Fi 


G.— Treatment  of  Fracture 
of  tlie  Siiriiieal  Neck. 


Fractures  of  the  Humerus.  45 

The  symjUoms  are  usually  well  marked ;  there  is 
an  increase  in  the  breadth  of  the  shoulder ;  a  projec- 
tion formed  by  the  detached  tuberosity  can  be  felt  at 
the  outer  and  back  part  of  the  joint,  while  between 
this  and  the  head  of  the  bone,  which  lies  beneath  the 
coracoid  process,  a  distinct  gap  or  vertical  sulcus  is 
evident ;  crepitus  is  absent  unless  the  fragments  are 
brought  into  aj)position  with  one  another. 

Treatment. — An  attempt  should  be  made  to  bring 
the  fragments  into  contact,  and  then  to  maintain  them 
so  by  pads  of  lint  and  strapping,  a  cap  being  also 
moulded  to  the  shoulder.  An  axillary  pad  will  often 
be  found  useful,  and  the  arm  should  also  be  supported 
in  a  sling  and  liandaged  to  the  side. 

ISeparatsoii  of  upper  epipliysis.— Separation 
of  the  upper  epiphysis  of  the  humerus,  which  includes 
the  head  and  both  tuberosities,  is  often  met  with  in 
young  subjects;  occurring,  as  it  does,  just  above  the 
usual  situation  of  fracture  through  the  surgical  neck, 
the  symptoms  of  the  two  injuries  are  very  similar.  In 
separation  of  the  epiphysis,  howtver,  the  lower  frag- 
ment is  smooth  and  rounded  instead  of  being  sharp 
and  irregular  as  in  fracture ;  crepitus  is  absent  or 
much  less  distinct,  owing  to  the  fact  that  the  line  of 
separation  runs  through  cartilage  and  not  through 
bone. 

The  treatment  is  the  same  as  m  tracture  through 
the  surgical  neck. 

Shalt. — Fracture  through  the  shaft  of  the  humerus 
is  often  met  with  as  the  result  either  of  direct  or 
indirect  force ;  it  usually  occurs  about  the  middle  of 
the  bone. 

If  the  fracture  is  above  the  insertion  of  the  deltoid, 
the  upper  fragment  is  drawn  inwards  by  the  pecto- 
ralis  major,  latissimus  dorsi,  and  teres  major ;  the 
lower  fragment  is  drawn  upwards  l>y  the  coraco- 
brachialis  and  biceps,  and  outwards  by  the  deltoid; 


40 


Manual  of  Surgery, 


consequently,  shortening  is  present  along  with  defor- 
mity^ the  lower  fragment  jorojecting  above,  behind,  and 
to  the  outer  side  of  the  upper  one. 

If  the  fracture  be  below  the  insertion  of  the  del- 
toid, the  displacement  is  often  very  slight  when  the 
line  of  fracture  is  transverse;  when,  however,  it  is 
oblique,  the  lower  fr.i:,nnent  is  drawn  upwards  by  the 
rJceps  and  triceps  so  as  to  overlap  the  uj^per  one.  The 
muKCulo-spiral  nerve,  o^ving  to  its  close  relationship 
with  the  middle  of  the  shaft  of  the  humerus,  is  liable 
to  be  wounded  at  the  time  of  fracture,  or  it  may  sub- 
sequently become  included  in  the  callus ;  under  these 
circumstances,  if  paralysis  of  the  nerve  accompanies 
or  follows  the  injury,  the  patient  will  present  evidences 
of  "  wrist-drop,"  with  loss  of  power  of  extension  and 
supination  in  the  fore-arm. 

j!^on-union  is  more  frequently  met  with  as  a 
complication  of  fracture  through  the  shaft  of  the 
humerus,  than  in  the  case  of  any  other  long  bone. 
Various  theories  have  been  advanced  to  account  for 
the  fact,  viz,  :  (1)  Interposition  between  the  fi'ag- 
ments  of  the  muscular  tissue  which  surrounds,  and  is 
directly  adherent  to,  the  shaft  of  the  bone.  (2)  Non- 
apposition  of  the  fragments  from  imperfect  support  to 
the  arm.  (3)  Injury  to  the  nutrient  artery  of  the 
bone.  (4)  Imperfect  fixation  of  the  shoulder  joint. 
(5)  The  tendency  to  movement  at  the  end  of  fracture, 
when,  the  elbow  joint  being  fixed  in  splints,  the  fore- 
arm is  flexed  or  extended. 

Treatment. — A  rectangular  splint  reaching  from 
the  axilla  to  the  fingers  should  be  applied  to  the  inner 
side  of  the  limb,  care  being  taken  that  it  is  well 
padded  where  it  presses  over  the  inner  condyle  and 
also  at  its  upper  end,  which  must  not  reach  too  high 
in  the  armpit;  three  short  splints,  reaching  from  the 
shoulder  to  the  elbow,  should  also  be  ap2)lied  to  the 
anterior,  posterior,  and  the  outer  aspects  of  the  upper 


Fractures  of  the  Humerus.  47 

arm.  In  most  cases  the  liancl  and  wrist  only  should 
be  supported  in  a  sling,  the  elbow  and  fore-arm  being 
allowed  to  hang,  so  that  the  weight  of  the  latter,  by 
dragging  on  the  lower  part  of  the  shaft,  may  counter- 
act the  tendency  to  overlapping  of  the  fragments, 
which  usually  exists. 

Stronieyer's  cushion,  a  triangular  wedge-shaped 
pad,  is  often  useful  in  cases  of  compound  fracture  ;  it 
is  interposed  between  the  chest  wall  and  arm  in  such 
a  way  as  to  form  a  support  for  the  limb,  the  elbow 
resting  upon  its  thick  end. 

Union,  as  a  rule,  takes  place  in  five  or  six  weeks, 

LiOi;ver  extremity. — Pbur  different  forms  of 
fracture  are  met  with  about  the  lower  end  of  the 
humerus,  viz.  transverse  supracondyloid,  T-shaped, 
separation  of  either  condyle  and  of  the  lower  epiphysis. 

Transverse  supracondyloid.  —  In  this  va- 
riety the  shaft  is  broken  across,  just  above  the  condyles; 
the  line  of  fracture,  though  transverse,  is  generally  some- 
what oblique  from  above  downwards  and  forwards,  so 
that  the  lower  fragment  is  drawn  upwards  behind  the 
upper  one  by  the  biceps,  brachialis  anticus,  and 
triceps.  The  symptoms  are  very  characteristic  ;  there 
is  an  irregular  projection  in  front  of  the  joint  above 
the  bend  of  the  elbow  formed  by  the  upper  fragment, 
which  pushes  forwards  the  brachial  artery,  and 
another  behind,  formed  by  the  lower  fragment  and 
bones  of  the  fore-arm.  Crepitus  and  abnormal 
mobility  are  present,  along  with  pain  and  swelling 
about  the  joint.  The  deformity  can  be  easily  reduced, 
but  at  once  re-appears  when  extension  is  left  off. 
The  distance  between  either  condyle  and  the  olecranon 
will  be  norma],  while  between  either  condyle  and  the 
acromion  it  will  be  diminished. 

If  the  line  of  fracture  runs  in  the  opposite  direction 
the  position  will  be  reversed,  the  lower  fragment 
being  drawn  upwards  in  front  of  the  upper  one. 


48  Manual  of  Surgery. 

This  fracture  is  liable  to  be  mistaken  for  dislocation 
of  the  radius  and  ulna  backwards ;  for  in  both 
injuries,  which  are  common  in  young  subjects,  there  is 
a  prominence  in  front  of  the  elbow  and  another 
behind,  with  loss  of  power,  and  pain  and  swelling 
about  the  joint.  The  diagnosis  of  fracture  can, 
however,  be  n^ide  by  attention  to  the  following  ])oints' 
the  presence  of  crepitus  and  increased  mobility  about 
the  lower  end  of  the  liumerus ;  the  fact  that  the 
anterior  projection,  which  is  formed  by  the  upper 
fragment,  is  rough  and  irregular,  and  above  the  bend 
of  the  elbow,  not  below  as  in  dislocation,  where,  being 
formed  by  the  articular  end  of  the  humerus  itself,  it 
is  broad,  smooth,  and  rounded ;  the  fact  that  there  is 
no  increase  in  the  distance  between  either  condyle  and 
the  olecranon,  while  shortening  is  present  on  measur- 
ing from  the  acromion  to  either  condyle ;  the  fact  that 
the  deformity  is  readily  reducible,  but  at  once  returns 
when  extension  is  discontinued,  will  usually  serve  to 
distinguish  fracture  from  dislocation. 

T-sliai>C€l  fracttare  into  the  joint. — In  this 
variety  there  is,  in  addition  to  a  transverse  fracture 
above  the  condyles,  a  vertical  crack  or  fissure  running 
between  them  and  involving  the  elbow  joint. 

Swelling  about  the  joint,  owing  to  effusion  into 
its  interior,  is  always  a  prominent  symptom,  often 
rendering  the  diagnosis  of  the  injury  somewhat 
dilHcult ;  the  lower  end  of  the  humerus  will  probably 
appear  to  be  somewhat  increased  in  width,  and 
crepitus  can,  as  a  rule,  be  readily  detected  on  flexing 
and  extending  the  fore-aim,  or  on  grasping  the  two 
condyles  and  moving  them  upon  each  other. 

Separation  of  citlaer  eonclyle, — Either  con- 
dyle of  the  humerus  may  become  separated  by  a  simple 
crack  or  fissure,  running  ol)liquely  across  the  lower  end 
of  the  bone.  In  separation  of  the  outer,  or  the  whole 
of  the  inner  condyle,   the  elbow  joint    is  necessarily 


Fractures  of  the  Humerus.  49 

opened.  In  the  case  of  the  inner  condyle,  it«  tip, 
which  is  more  prominent  and  consequently  mr»re 
liable  to  fracture,  is  often  separated  ("  epicondylar 
fracture ")  without  the  joint  being  ijivolved.  There 
is  not,  as  a  rule,  much  displacement  of  the  fractured 
condyle,  though  at  times  it  is  drawn  down  by  the 
muscles  attached  to  it,  so  that  the  characteristic 
projection  on  either  side  of  the  joint  is  lost.  The 
elbow  becomes  painful  and  swollen,  its  movements  are 
impaired,  and  crepitus  can  readily  be  detected. 

In  fracture  of  the  external  condyle  the  musculo- 
spiral  nerve  or  its  subdivisions  (^raore  especially  the 
posterior  interosseous),  and  in  fracture  of  the  internal 
condyle  the  ulnar  nerve,  may  become  wounded  at  the 
time  of  injury,  or  afterwards  included  in  the  callus  by 
which  repair  is  effected.  Under  these  circumstances 
symptoms  of  paralysis  of  these  nerves  will  accompany 
or  follow  the  fracture. 

Separation  of  lower  epiphysis, — Separation 
of  the  lower  epiphysis  of  the  humerus,  viz.  of  the  two 
condyles  with  the  trochlea  and  capitellum,  is  often  met 
with  in  young  subjects,  as  the  result  of  a  fall  upon  the 
elbow.  Occurring  almost  in  the  same  situation  as  the 
transverse  supracondyloid  fracture,  the  symptoms  are 
very  similar  to  those  met  with  in  that  injury.  In  se- 
paration of  the  epiphysis,  however,  the  fragments  are 
more  smooth  and  rounded  than  in  fracture,  and  for 
this  reason,  crepitus  is  less  distinct  or  altogether  absent. 
The  line  of  separation  is  also  just  above  the  joint, 
nearer  to  it  than  is  often  the  case  in  fracture. 

In  rare  cases  the  trochlea  and  capitellum  only  are 
separated,  the  condyles  being  left  attached  to  the 
shaft  of  the  bone,  the  so-called  "  infracondyloid 
separation  of  epiythysis. " 

Treatuient. — JMost   cases   of  fracture  of  the  lower 
end  of  the  liumerus  may  be  treated   witli   an   internal 
rectangular  splint,  reaching  well  up  the  arm  and  down 
E— 21 


50  Manual  op  Surgery. 

to  tljc  lingers ;  the  elbow  bhoiild  be  ke})t  at  a  right 
angle,  and  the  fore-arm,  in  a  position  midway  between 
pronation  and  supination,  should  be  supported  in  a 
sling.  Some  cooling  lotion  should  be  applied  to  the 
joint  when  evidences  of  synovitis  are  present. 

In  separation  of  the  lower  epiphysis  and  in  trans- 
verse supracondyloid  fractui'e,  when  the  fragments 
cannot  be  kept  in  position  by  this  treatment,  it  is 
sometimes  recommended  to  apply  an  angular  splint, 
fitting  the  bend  of  the  elbow,  to  the  front  of  the  limb, 
and  a  straight  splint  to  the  back  of  the  upper  arm,  so 
as  to  push  the  U})pcr  fragment  backward,  and  the 
elbow  with  the  lower  one  forward ;  or  the  position  of 
the  splints  may  be  reversed,  the  angular  one  being 
applied  behind,  and  the  straight  one,  reaching  to  the 
bend  of  the  elbow,  in  front ;  care  should,  however, 
always  be  taken  that  too  much  pressure  is  not  em- 
ployed, otherwise  there  is  a  risk  of  the  supervention 
of  gangi'ciu;  from  com])r(3Ssion  of  the  brachial  artery 
between  the  shaft  of  the  humerus  and  the  anterior 
splint. 

At  the  end  of  two  or  three  weeks  passive  move- 
ment should  be  cautiously  commenced,  the  splints 
being  removed  and  re-applied  daily.  When  the  joint 
is  in\olvcd,  it  is  sometimes  advisable,  especially  with 
children,  to  commence  at  an  earlier  period,  e.g.  as 
soon  as  ten  days  after  the  accident.  In  most  cases, 
however,  more  or  less  stiffness  will  remain  for  a  time, 
and  Avliere  the  elbow  joint  is  implicated,  the  patient 
should  be  i)repared  for  the  impairment  in  its  move- 
ments, which  is  often  permanent. 

Firm  union  will,  as  a  rule,  take  place  in  from  four 
to  six  weeks. 

In  cases  of  compound  fracture  involving  thfe  elbow 
joint,  an  attempt  should  be  made  to  save  the  limb, 
unless  tJie  soft  tissues  are  extensively  lacerated  and 
theie  is  much  splintering  of  bone  ;  any  loose  fragments 


h'RACrURES    OF    THE    FoRE-ArM.  5I 

should  be  removed,  and  occasionally  a  piimaiy 
excision  of  the  joint,  cithor  partial  or  conipletu,  niay 
be  re<|uii"cd.  A  plaster  of  Paris  splint,  interrupted 
at  the  elbow  with  pieces  of  strong  wiie,  iron  hoop, 
etc.,  will  be  found  a  useful  apparatus  in  these  cases,- 
as  it  allows  access  to  the  wound  for  dressing,  and  at 
the  same  time  keeps  the  part  in  a  state  of  perfect 
rest. 

The  Fore- Arm. 

Fractures  of  one  or  both  of  the  bones  of  the  fore- 
arm are  of  very  frequent  occurrence. 

Radiuis  :iii€l  iiliia. — Fracture  of  both  i-;iKus  and 
ulna  is  often  met  Avith,  generally  as  (he  result  of 
direct  violence,  a  fall  upon  the  hand  being  more  com- 
monly followed  by  fracture  of  the  radius  alone  than  of 
both  bones.  The  usual  situation  is  through  their 
middle  or  lower  third,  their  upper  third  being  better 
protected  by  the  thick  covering  of  muscles.  The  line  of 
fracture  is  usually  transverse,  both  bones  are  broken 
on  the  same  level,  or  nearly  so.  The  upper  fragments 
are  drawn  forwards  by  the  action  of  the  biceps,  pro- 
nator teres,  and  brachialis  anticus,  the  radius  being 
someAvhat  approximated  to  the  ulna.  The  lower  frag- 
ments are  drawn  together  by  the  pronator  quadratus, 
and  upwards,  either  in  front  of  or  behind  the  upper 
fragments,  by  the  flexor  and  extensor  muscles. 

There  is  more  or  less  shortening  of  the  fore-arm, 
with,  in  many  cases,  considerable  deformity,  the  lower 
fragments,  which  usually  overlap  the  upper,  forming 
a  projection  on  either  the  anterior  or  })osterior  surface 
of  the  limb ;  crepitus  can  be  readily  detected,  and 
abnormal  mobility  is'  also  present. 

Trcatineid. — The  fore-aim  should  be  bent  to  a  right 
angle  and  placed  in  a   position  midway  between  pro 
nation  and  supination,  i.e.  with  the  thumb  pointing 
upwards.      Two   straight   splints,  reaching    from    the 


52  Manual  of  Surgerv. 

elbow  to  the  fingers,  should  be.  applied  to  the  anterioi* 
and  posterior  surfaces  of  the  limb.  In  this  posi- 
tion the  radius  and  ulna  will  be  parallel  with  one 
another,  and  the  interosseous  space  will  consequently 
be  preserved.  The  splints  should  be  slightly  broader 
than  the  limb,  so  that  the  bandages  may  not  press 
upon  the  arm  and  force  the  bones  together.  In  some 
cases  it  may  be  necessary  to  apply  a  narrow  pad  along 
the  interosseous  space,  in  order  to  keep  the  radius  and 
ulna  apart ;  otherwise  they  might  become  united 
together  by  callus  thrown  out  across  the  space,  a 
result  which  would  afterwards  interfere  with  the 
movements  of  pronation  and  supination. 

Union  is  generally  effected  in  from  three  to  four 
weeks. 

Usicliuis. — Fracture  of  the  radius  alone  may  take 
place  through  its  neck,  shaft,  or  lower  end,  the  latter 
situation  being  the  most  common. 

IVeck. — Fracture  through  the  neck  of  the  radius  is 
an  uncommon  injury,  and  one  that  is  often  difficult  to 
detect,  owing  to  the  fact  that  very  little  displacement 
of  the  fragments  is  usually  present,  the  bone  at  this 
spot  being  surrounded  by  a  layer  of  muscle.  The 
movements  of  the  fore-arm,  especially  supination  and 
pronation,  are  interfered  with  ;  on  placing  the  finger 
over  the  fracture  and  rotating  the  hand,  crepitus  can 
be  detected,  and  unless  the  fragments  are  interlocked, 
the  head  of  the  radius  will  not  rotate  with  the  shaft  of 
the  bone. 

The  treatment  is  the  same  as  in  fracture  through 
the  shaft. 

Sliiift* — Fracture  through  the  shaft  of  the  i-adius 
is  more  common  than  fracture  of  the  idna  alone,  for, 
being  situated  on  the  outer  aspect  of  the  liinl),  it  is 
more  exposed  to  direct  violence  ;  moreover,  its  shaft  is 
not  so  strong  as  that  of  the  ulna,  and  it  also  has  a 
more  direct   connection  with  the  wrist.     It  may  be 


CoLLEs'  Fracture.  .   53 

due  to  direct  violence  or  to  a  fall  upon  the  hand. 
The  usual  seat  of  fracture  is  about  its  middle;  if 
above  the  insertion  of  the  pronator  teres,  the  upper 
fragment  is  flexed  by  the  biceps  and  fully  supinated  by 
the  supinator  brevis ;  if  below,  the  upper  fragment 
will  be  in  a  position  midway  between  pronation  and 
su2:)ination,  the  action  of  the  supinator  brevis  being 
more  or  less  counteracted  by  that  of  the  pronator 
teres.  The  lower  fragment  is  pronated  and  drawn 
towards  the  ulna  by  the  pronator  quadratus.  The 
symptoms  are  usually  well  marked  :  a  prominence  is 
formed  on  the  front  of  the  upper  part  of  the  fore-arm 
by  the  upper  fragment,  and  there  is  a  depression  at 
the  seat  of  fracture,  both  fragments  being  drawn 
inwards  towards  the  ulna.  Crepitus  is  produced  on 
pressing  the  fragments  together,  or  on  rotating  the 
hand,  and  there  is  loss  of  power  of  pronation  and 
supination,  with  abnormal  mobility. 

The  treatment  is  the  same  as  in  fracture  of  both 
bones  of  the  fore-arm.  When,  however,  the  radius  is 
broken  high  up,  it  is  sometimes  necessary  to  keep  the 
fore-arm  well  supinated  by  means  of  an  angular  splint 
applied  to  the  back  of  the  upper  arm  and  fore-arm,  for, 
the  upper  fragment  being  fully  supinated,  the  proper 
axis  of  the  limb  will  not  be  maintained  if  the  lower 
one  is  kept  in  a  position  midway  between  pronation 
and  supination,  as  in  the  ordinary  method. 

L.ower  extremity.— Fracture  of  the  lower  end  of 
the  radius  is  very  common,  one  variety  being  known  as 
"Colles'  fracture,"  after  the  celebrated  Dublin 
surgeon,  who  was  the  first  to  accurately  describe  it. 
It  is  generally  the  result  of  a  fall  upon  the  palm  of 
the  hand  when  the  arm  is  extended,  and  though  met 
with  at  all  ages  and  in  both  sexes,  is  more  common 
after  middle  life,  and  especially  in  females. 

The  seat  of  fracture  is  usually  half  an  inch  to  one 
and  a  half  inches   above  its  lower  end,  just  at  the 


54  .  Manual  of  Surgery. 

weakest  portion  of  the  radius,  i.e.  where  tlio  yhaft 
begins  to  expand  into  the  broad  articular  extremity, 
wliioli  is  mainly  composed  of  cancellous  tissue,  covered 
witJi  a  layer  of  compact  bone  mucli  thinner  than  that 
of  tlie  shaft  itself.  The  line  of  fracture  is  generally 
transverse,  but  may  be  oblique  from  side  to  side,  or 
from  before  backwards ;  in  some  cases  there  is  com- 
minution of  the  lower  fragment,  and  not  unfrequently 
the  fracture  is  impacted,  the  compact  tissue  of  the 
shaft  being  driven  into  the  cancellous  tissue  of  the 
lower  fragment  by  the  same  force  that  causes  the 
injury.*  The  amount  of  displacement  varies  ;  in  some 
cases  scarcely  any  is  present ;  more  commonly  it  ia 
considerable,  and  in  Colles'  fracture  a  veiy  charac- 
teristic deformity  is  usually  produced,  viz.  : 

The  lower  fragment,  carrying  with  it  the  hand,  is 
driven  upwards  and  backwards  behind  the  upper  one 
by  the  direction  of  the  force  and  the  combined  action 
of  the  supinator  longus,  extensors  of  the  thumb,  and 
radial  extensors,  so  that  a  prominence  is  formed  on  the 
back  of  the  wrist,  with  a  depression  above  it. 

The  upper  fragment  projects  forwards,  often 
lacerating  the  pronator  quadratus,  and  is  drawn  by 
this  muscle  towards  the  ulna,  forming  a  prominence 
on  the  front  of  the  fore-arm  just  above  the  wrist  from 
the  flexor  tendons  being  thrust  forwards.  There  is 
some  difference  of  opinion  as  to  whether  the  fracture 
is  generally  impacted  or  not ;  when  the  deformity  is 
])ermanent,  and  cannot  be  made  to  disap])car,  impac- 
tion is  probably  present ;  when,  on  the  other  hand, 
the  fracture  is  readily  r(;ducible,  impaction  is  absent. 

*  ]Mr.  Clement  Lucas  lias  recently  shown  that  in  Colics' 
fracture,  in  ailditinn  to  fracture  of  the  radius,  "there  is  usually 
either  a  fracture  of  the  styloid  process  of  the  \ilna,  or  a  tear  of  the 
internal  lateral  ligament  of  the  wrist  joint,  and,  in  addition,  fre- 
fjuently  a  rupture  of  the  triangular  fibro-cartilago,"  the  latter 
becoming  detached  from  the  edge  of  the  radius  (Guy's  Hoepital 
Reports,  vol.  xlii,). 


CoLLEs'  Fracture.  55 

The  symptoms  are  as  follows  :  pain  and  swelling 
about  the  wrist,  with  impaired  movement,  especially 
of  pronation  and  supination.  On  viewing  the  limb 
sideways,  its  posterior  surface  presents  a  distinct 
prominence  (formed  by  the  lower  fragment)  just  above 
the  wrist ;  a  little  higher  up  a  marked  depression  will 
be  seen.  Its  anterior  surface  presents  a  depression 
above  the  wrist,  corresponding  in  position  with  the 
dorsal  projection,  and  most  marked  on  its  radial 
margin;  while  higher  up,  and  corresponding  with 
the  dorsal  depression,  a  distinct  prominence  is  seen, 
formed  by  the  jirojection  forwards  of  the  upper 
fragment. 

On  viewing  the  back  of  the  limb  it  will  be  seen 
that  the  hand  is  drawn  over  to  the  radial  side,  so  tliat 
its  ulnar  border  is  somewhat  convex ;  the  styloid 
process  of  the  ulna  (or,  when  this  is  fractured,  the 
lower  end  of  the  ulna  itself)  is  unusually  prominent ; 
the  radial  border  of  the  wrist  is  slightly  concave. 
When  the  styloid  process  of  the  ulna  is  not  fractured, 
the  tips  of  the  two  styloids  will  often  be  found  on  the 
same  level. 

When  the  fragments  are  not  impacted,  crepitus 
can,  as  a  rule,  be  readily  detected,  the  deformity  can 
be  made  to  disappear,  and  the  bones  brought  into  good 
position.  If,  however,  impaction  is  present,  crepitus 
is  absent,  and  the  deformity  is  permanent,  unless  the 
fragments  are  forcibly  loosened  from  one  another. 

Treatment. — An  attempt  should  be  made  to  reduce 
the  fracture,  and  when  impaction  is  absent,  or  not 
very  lii'm,  this  can  usually  be  eflccted,  the  deformity 
then  disappearing  more  or  less  comidetely.  If,  how- 
ever, the  ends  of  the  bone  are  so  fixed  that  they 
cannot  be  disengaged  by  the  employment  of  moderate 
force,  union  will  take  place  between  the  impacted 
fragments,  and  the  wrist  will,  in  consequence,  remain 
stitf  and  deformed. 


56 


Manual  of  Surgery. 


YU.  7. 


-Nelaton's  Splint  foi*  Colles' 
Fractiu'e. 


In  the  treatment  of  this  fracture  many  different 
forms  of  apparatus  are  employed. 

Two  straight  s]:)lints  may  be  used,  a  palmar  one 
reaching  from  the  elbow  to  the  lower  end  of  the  upper 

fragment,  and  a  dorsal 
from  the  same  point  to 
the  ends  of  the  fingers. 
A  thick  ])acl  should  be 
placed  over  the  end  of 
the  upper  fragment,  and 
another  over  the  lower 
fragment,  so  as  to  press 
them  into  position.  At 
the  end  of  a  week  a 
shorter  dorsal  splint  should  be  substituted,  viz.  one 
reaching  only  to  the  knuckles,  so  as  to  leave  the 
fingers  free. 

Nelaton's  pistol  splint  (Fig.  7)  is  curved  at  one 
end  like  the  handle  of  a  pistol,  so  as  to  draw  the  hand 
over  to  the  ulnar  side ;  it  is  usually  applied  to  the 
back    of  the   fore-arm 

and    hand     (less     fre-  -^^  v^s^s^ 

quently  to  the  front) 
in  conjunction  with  a 
short  straight  splint, 
reaching  fiom  the  el- 
bow to  the  lower  end 
of  the  upper  fragment, 

applied  to  the  front  of  the  arm.  The  pistol  splint 
should  bo  thickly  pndded  where  it  presses  on  the  lowei' 
fr;ignicnt,  and  the  palmar  one  where  it  presses  on  the 
radial  border  of  the  fore-arm  and  lower  end  of  the 
upper  fragment. 

Carr's  splint  (Fig.  8)  is  ai)plied  to  the  palmar 
surface  of  the  hand  and  arm  in  the  prone  position,  the 
fingers  grasping  the  cross  bar  which  lies  beneath 
the    metacarpo-phalangcal    joints ;     a    short    straight 


Fiff.   8. 


-Carr's.  Splints  for  Colles* 
Fracture. 


Fractures  of  the  Ulna.  57 

splint  is  also  applied  to  the  dorsal  surface  of  the 
fore-ariii. 

Whatever  treatment  is  adopted,  care  should  be 
taken  that  the  fingers  are  left  free,  and  the  patient 
made  to  exercise  them  after  the  first  week.  The  splints 
may  generally  be  removed  at  the  end  of  three  or  four 
weeks,  and  gentle  passive  movement  of  the  wrist  joint 
should  then  be  commenced,  otherwise  more  or  less 
stiflness  of  the  part  will  remain.  In  many  cases,  how- 
ever, and  especially  in  old  peo])le,  in  spite  of  the  most 
careful  treatment,  the  wrist  joint  will  never  quite 
recover  its  normal  shape  or  movement. 

Ulna.  —  Fracture  of  the  ulna  alone  may  occur 
through  the  olecranon,  shaft,  or  styloid  process,  and  in 
rare  cases  through  the  coronoid  process. 

Olecranon. — Fracture  of  the  olecranon  is  not 
uncommon  as  the  result  of  direct  violence,  e.g.  falls,  or 
blows  on  the  back  of  the  elbow  ; '  more  rarely  it  is  due 
to  sudden  and  violent  contraction  of  the  trice})s 
muscle. 

More  or  less  deformity  is  generally  present,  the 
broken  fragment  being  drawn  upwards  by  the  action 
of  the  triceps.  The  nearer  the  fracture  is  to  the  tip  of 
the  process,  the  greater  is  the  displacement,  often  to 
the  extent  of  an  inch  or  more.  When  the  fracture  is 
near  its  base,  very  little  separation  is  often  present, 
the  fractured  process  being  tken  retained  in  position  by 
the  periosteum  and  fibrous  tissue  which  invest  it. 

When  separation  of  the  fragments  is  present,  the 
prominence  of  the  elbow  is  replaced  by  a  depression, 
which  is  increased  when  the  fore-arm  is  bent.  Swelling 
rapidly  ensues  from  effusion  into  the  joint.  The  power 
of  extending  the  fore-arm  is  lost.  Crepitus  is  al)sent, 
unless  the  fractured  process  is  drawn  down  into  con- 
tact with  the  surface  of  the  ulna.  When  no  separation 
of  the  fragments  lias  occurred,  the  depression  at  the 
back  of  the  elbow  will  not  be  present ;  there  will  only 


58  Manual  of  Surgery. 

be  slight  loss  of  power  in  the  arm,  and  crepitus  can 
readily  be  obtained. 

Union  is  usually  effected  by  fibrous  tissue,  whicb 
may  afterwards  yield  and  allow  of  considerable  separa- 
tion of  the  fragments ;  the  result  is  that  the  arm  is 
often  left  considerably  weakened,  the  power  of  ex- 
tending the  fore-arm  being  more  or  less  impaired. 

Treatment. — A  straight  splint  should  be  applied 
to  the  front  of  the  limb,  more  thickly  padded  where 
it  fits  the  bend  of  the  elbow,  so  that  the  joint  may  be 
very  slightly  bent ;  it  will  generally  be  found  that  the 
fragments  come  into  more  accurate  contact  in  this  posi- 
tion than  if  the  arm  is  kept  perfectly  straight. 

When  separation  of  the  fragments  is  present,  the 
upper  one  should  be  drawn  down  by  strapping,  and  a 
figure  of  8  bandage,  as  in  the  case  of  the  patella.  As 
the  fracture  usually  involves  the  joint,  and  is  followed 
by  effusion  into  its  iiiterior,  it  will  often  be  necessary 
to  subdue  the  swelling  by  some  evaporating  lotion 
before  the  fracture  can  be  put  up.  Union  generally 
takes  place  in  four  to  six  weeks,  and  at  the  end  of  this 
period  passive  movement  should  l)e  commenced,  other- 
wise ankylosis  of  the  joint  may  take  place. 

In  cases  where  separation  of  the  fragments  sub- 
sefpiently  occurs  from  yielding  of  the  fibrous  tissue 
by  which  union  is  effected,  a  similar  plan  of  treatment 
to  that  described  in  the  case  of  the  patella  (page  S3) 
may  be  adopted,  viz.  opening  the  joint  and  wiring  the 
fragments  ;  a  few  cases  of  recent  fracture  have  also 
been  treated  in  the  same  way. 

Coronoitt  process. — Fracture  of  the  coronoid 
process  is  extremely  rare,  except  as  a  comi)lication  of 
dislocation  backwards  of  the  ulnn.  The  broken  frag- 
ment may  be  drawn  upwards  by  the  brachialis  anticus. 

Treatment. — The  limb  should  be  put  up  in  splints  at 
a  right,  or  even  at  an  acute,  angle,  in  order  to  relax  the 
niuscle  which  tends  to  displace  tlie  separated  process. 


Fractures  of  the  Hand.  59 

Shaft. — Fracture  of  the  shaft  of  the  uhia  usually 
occurs  through  its  lower  third,  this  being  the  weakest 
part  of  the  bone  ;  it  is  most  commonly  the  result  of 
direct  violence.  Tlie  lower  fragment  is  drawn  towards 
the  radius  by  the  pronator  quadratus,  the  upper  frag- 
ment retaining  its  normal  position,  or  being  slightly 
displaced  forwards  by  the  brachialis  anticus.  A  slight 
irregularity  is  present  in  the  course  of  the  bone  at  the 
seat  of  fracture,  crepitus  can  bo  detected,  and  the 
movements  of  the  fore-arm  are  impaired. 

The  treatment  is  the  same  as  in  fracture  of  both 
bones  of  the  fore-arm. 

Styloicl  process. — Fracture  of  the  styloid  process 
sometimes  takes  place,  often  occurring  in  cases  of 
CoUes'  fracture. 

The  Hand. 

Carpus. — Fractures  of  the  carpal  bones  are  of 
rare  occurrence ;  when  present,  they  are  usually  due  to 
direct  violence,  e.g.  a  severe  crush  or  blow.  Owing  to 
their  numerous  ligamentous  connections,  very  little 
displacement  takes  place,  though  crepitus  is  generally 
a  prominent  symptom. 

Treatment. — The  fore-arm  and  hand  should  be  sup- 
ported on  an  anterior  splint,  and  some  cooling  lotion 
applied  over  the  wrist  to  subdue  the  inflammation  of 
the  neighbouring  joints  which  is  usually  present. 

Metacarpus. — Fractures  of  the  metacarpal  bones 
are  not  uncommon  as  the  result  of  direct  violence,  the 
most  common  situation  being  through  their  middle  or 
distal  third.  The  displacement  of  the  fragments  is  in 
some  cases  very  sliglit,  while  in  others  it  is  considerable, 
the  head  of  the  bone  dropping  or  sinking  forwards 
towards  the  palm,  and  the  fractured  ends  being  dis- 
phiced  backwards  so  as  to  form  an  angular  projection 
on  the  back  of  the  hand. 

Treatment. — In  many  cases  an  anterior  splint  witlj 


6o  Manual  of  Surgery. 

a  palmar  pad  is  all  that  is  required.  When  there  is 
much  displacement  of  the  fragments,  a  palmar  pad 
pressing  upon  the  head  of  the  bone,  and  another  one 
over  the  dorsal  projection  with  anterior  and  posterior 
splints,  will  often  be  found  useful.  Bending  the 
fingers  over  a  ball  or  thick  pad,  and  then  bandaging 
them  in  this  position,  is  another  plan  of  treatment 
sometimes  adopted.  Union  generally  takes  place  in 
three  or  four  weeks. 

Phalaiig'cs. — Fractures  of  the  phalanges  can 
readily  be  recognised  by  the  presence  of  crepitus,  ab- 
normal mobility,  and  displacement  of  the  fragments. 

Treatment. — A  narrow  splint  should  be  applied  to 
the  anterior  suiface  of  the  finger. 

The  Pelvis. 

Fracture  of  the  bones  of  the  pelvis  is  usually  the 
result  of  severe  direct  violence,  and  when  compli- 
cated, as  is  often  the  case,  witli  injury  to  the  bladder, 
urethra,  and  other  contents  of  the  pelvis,  is  always 
of  a  serious  nature. 

1.  TBii-ougli  crest  of  iliuin. — Fractures  sepa- 
rating only  a  portion  of  the  crest  of  the  ilium  are  not 
generally  attended  by  much  danger.  The  nature  of  the 
injury  is  usually  evident,  for,  in  addition  to  more  or 
less  pain  and  bruising  about  the  seat  of  fracture,  there 
will  be  mobility  of  the  broken  fragment,  with  crepitus 
on  manipulation. 

2.  Tlii'oiig-h  pelvic  basin. — Fractures  involv- 
ing the  pelvic  basin  are  much  more  serious,  owing  to 
tlie  fact  that  the  viscera  contained  in  it  are  so  liable  to 
injury.  In  many  cases  the  fracture  is  multiple  ;  e.g.  it 
may  involve  Ijoth  rami  of  tlie  pubes,  and  sometimes,  in 
addition,  botli  rami  of  the  ischium,  so  tliat  the  central 
portion  of  the  pelvis  is  entirely  separated  ;  or  it  may 
involve  the  rami  of  the  pubes  and  ischium  in  front, 


Fractures  of  the  Pelvjs.  6i 

arid  the  ilium  behind,  close  to  the  sacro-iliac  synchon- 
drosis, so  as  to  separate  one  half  of  the  pelvis. 

The  symptoms  of  the  injuiy  are  usually  manifest, 
for  in  addition  to  the  bruising  of  the  soft  parts,  there 
is  severe  pain, especially  upon  any  attempt  atmovement, 
with  inability  to  stand  or  sit  erect :  a  line  of  ecchy- 
mosis  is  often  present,  extending  along  Poupart's 
ligament  and  the  crest  of  the  ilium,  with  discoloration 
of  the  skin  over  the  sacrum  and  in  the  perinseum  ; 
crepitus  and  abnormal  mobility  can  often  be  detected 
on  grasping  the  iliac  spines  or  crests  and  attempting 
to  rotate  or  move  them  on  each  other  ;  in  some  cases 
the  displacement  of  the  fragments  will  be  evident, 
especially  on  examination  by  the  rectum  or  vagina. 

When  the  bladder  or  urethra  is  injured  there 
will  also  be  evidence  of  these. complications. 

3.  Tliroiigli  acetabitliiiii. — Fracture  may  take 
place  through  the  rim  or  floor  of  the  acetabulum  owing 
to  the  head  of  the  femur  being  driven  violently 
against  it. 

{a)  Through  floor. — Fracture  through  the  floor  may 
occur  as  a  simple  crack  or  fissure,  or  there  may  be 
extensive  splintering  of  the  pelvic  bones.  In  the  former 
case  there  may  be  no  very  evident  symptoms,  with 
the  exception  of  pain,  especially  on  attempts  to  move 
the  limb  or  stand  erect,  or  upon  pressure  on  the  pubes  ; 
at  first  there  is  not  any  alteration  in  the  length  of  the 
limb,  but  after  a  time  slight  shortening  may  ensue, 
probably  owing  to  changes  taking  place  in  the  cai-ti- 
lage  of  the  head  of  the  femur  and  acetabulum,  and 
leading  to  absorption  of.  the  articular  surfaces  of  tlie 
bones.  In  the  latter  case,  crepitus  can  be  readily  de- 
tected on  any  movement  of  the  limb,  and  if  the  head 
of  the  femur  is  driven  into  the  pelvic  cavity,  there 
will  be  shortening  of  the  leg  with  inability  to  move  it, 
deformity  of  the  hip,  and  probably  evidences  of  injury 
to  the  contents  of  the  pelvis. 


62  Manual  of  Surgerv. 

(b)  Thi'ouf/k  rim. — In  fracture  through  the  rim 
of  the  acetabulum,  it  is  usually  its  upper  and  posterior 
])art  that  gives  way  ;  consequently  the  head  of  the 
femur  is  liable  to  slip  out  of  its  socket,  and  the  injury 
is,  therefore,  frequently  accompanied  by  a  dislocation 
of  the  thigh  on  to  the  dorsum  ilii.  When  this  is  the 
case,  the  symptoms  are  usually  obvious ;  in  addition 
to  those  characteristic  of  dislocation,  there  will  be 
distinct  crepitus,  and  it  will  be  found  that  the  dislo- 
cation can  easily  be  reduced,  but  will  at  once  return 
when  extension  is  discontinued. 

4.  Tlii-oiigli  sacriiiii. —  Fracture  through  the 
sacrum  is  of  rare  occurrence  except  as  the  result  of 
gun-shot  injury  ;  when  due  to  other  causes,  e.g.  severe 
crushes,  etc.,  it  is  usually  associated  with  fracture  of 
the  other  pelvic  bones,  evidences  of  which  will  be 
present. 

5.  Tlii'oiigli  coccyx.  —  Fracture  through  the 
coccyx,  or  dislocation  of  this  bone  from  the  sacrum,  is 
sometimes  met  with  as  the  result  of  direct  violence, 
or  occurring  during  the  straining  efibrts  of  parturition. 
The  symptoms  are  pain  at  the  part,  increased  on 
sitting,  walking,  and  during  the  act  of  defsecation  ; 
crepitus  and  abnormal  mobility  will  sometimes  be 
present,  and  on  introducing  the  linger  into  the  rectum 
a  slight  projection  will  probably  be  felt  on  its  posterior 
wall.  In  some  cases  this  injury  is  followed  by  i)er- 
sistent  pain  ("coccydynia")  in  the  region  of  the 
coccyx. 

Treatment. — The  patient  should  be  kept  in  the 
recumbent  position,  and  a  bioad  bandage,  padded 
belt,  felt  or  guttapercha  sj^lint  moulded  to  the  part, 
applied  to  the  pelvis  so  as  to  kei^p  the  parts  com- 
[»l(itely  at  rest ;  in  many  cases  it  will  also  be  advisable 
to  tie  tiie  knees  together. 

In  fracture  of  the  acetabulum,  extension  should  be 
emi>loyed  by  means  of  an  outside  splint,  as  in  fracture 


pRACrURES   OF    THE  pEMUK.  6^ 

of  the  thigh  ;  this  is  especially  necessary  when  its  riin 
is  involved,  in  order  to  ju'event  the  head  of  the  feiiiur 
from  becoming  displaced.  Any  complication  which 
may  be  present,  e.g.  rupture  of  bladder  or  urethra, 
must  be  treated  on  ordinary  piincii)les. 

In  fas'ourable  cases,  repair  will  be  effected  in  from 
six  to  eight  weeks. 

The  Femur. 

Fractures  of  the  femur  may  be  divided  into 
fractures  of  the  neck,  great  trochanter,  shaft,  and 
lower  extremity. 

1.  Ncclc. — Fractures  of  the  neck  of  the  femur  may 
be  subdivided  into  two  great  classes,  viz.  intracapsular 
and  extracapsular,  according  as  the  bone  is  broken 
within  or  without  the  line  of  insertion  of  the  ca[);sular 
ligament.  In  many  instances,  however,  the  line  of 
fracture  lies  partly  within  and  partly  without  the  in- 
sertion of  the  capsule.  In  either  case  the  fracture 
may  be  impacted  or  non-im2:)acted. 

Intracapsular  fracture  is  an  injury  of  ad- 
vanced, life,  being  rarely  met  with  in  persons  under  fifty 
years  of  age  ;  it  is  especially  common  in  the  female  sex, 
and  is  usually  the  result  of  slight  indirect  violence,  e.(j. 
catching  the  foot  and  trippuig  up,  missing  a  step  in 
going  downstairs,  etc. ;  consequently  it  is  not,  as  a  rule, 
attended  by  any  bruising  or  apparent  injury  to  the 
soft  parts  about  the  hip.  Its  frequent  occurrence  in 
old  people  is  no  doubt  owing  to  the  alterations  in 
structure  and  shape  which  take  place  in  the  neck  of 
the  bone  as  age  advances.  Not  only  is  its  nutrition 
impaired,  as  shown  by  the  fatty  degeneration  of  the 
cancellous  and  the  thinning  of  the  com})act  tissue, 
but  the  neck  of  the  bone  itself  also  becomes  more 
horizontal,  being  set  almost  at  a  right  angle  to  the 
shaft ;  consequently,  becoming  weakened  from  ])oth 
these  causes,  it  is  liable  to  t>nap  and  give  way  as  the 


bd 


Manual  of  Surgery. 


result  of  the   application   of  a  very  slight  degree  of 
violence. 

The    fracture   may   be   either   impacted    or    non- 
impacted,  the  latter  l)eing  hy  far  the  niont  com  in  on. 

In  the  iioii-iiii|>actefl  variety  the  amount  of  dis- 
placement of  the  fragments  varies ;  in  most  cases  the 

lower  fragment  is 
drawn  upwards, 
ahove  and  to  the 
outer  side  of  the 
upper  one,  and  at 
the  same  time  ro- 
tated outwards,  so 
that  its  fractured 
surface  looks  more 
or  less  directly 
forward,  while  the 
upper  fragment, 
being  unacted  upon 
by  any  muscles, 
retains  its  normal 
position.  In  cases 
where  the  perios- 
teum and  reflection 
of  capsule,  which 
in\'est  the  neck 
of  the  bone,  are 
not  torn  through 
at  the  time  of  the  injury,  the  separation  of  the  frag- 
ments may  at  first  be  very  slight. 
The  syiiiptoiiis  are  as  follows  : 
Alteration  in  the  shape  of  the  hip,  which  is  some- 
what flattened.  Alteration  in  the  position  of  the 
trochanter  major,  Avhich  is  less  jn-ominent  than  usual, 
and  approximat(Ml  to  the  anterior  superior  iliac  spine 
and  also  to  the  median  line  of  the  body.  On  rotating 
the  limlj  it  u'ill  also  l)e  found  that  the  trochanter  moves 


Fig.  9.— The  most  common  Fractures  of  the 
Upper  End  of  the  Femur.  (From  Pick's 
•'  Fractures  and  Dislocations.") 


Fractures  of  the  Femur. 


65 


through  a  smaller  segment  of  a  circle  than  on  the 
sound  side. 

To  verify  the  altered  position  of  the  trochanter 
major,  the  following  tests  may  be  employed. 

(a)  Nelaton^s  line. — In  fracture  of  the  neck,  as  in 
a  dorsal  dislocation  of  the  femur,  the  upjDcr  border  of 
the  trochanter  will  lie  above  a  line  drawn  from  the 
anterior  superior  iliac  spine  to  the  tuber  ischii. 

In  the  normal  condition,  the  upper  border  of  the 
trochanter  should  just  touch  this  line. 

{b)  Bryant's  ilio-femoral  triangle. — This  (a  b  c, 
Fig.  10)  consists  of  three  lines;   viz.  a  b,  drawn  from 


Fig.  10.— Bryant's  Triangle.   (From  Bryant's  "  Practice  of  Surgery.") 


the  anterior  superior  iliac  spine  to  the  upper  border  of 
the  trochanter  major,  corresponding  in  the  normal 
state  to  the  u]')per  part  of  Nelaton's  line ;  a  c,  drawn 
from  the  iliac  spine  at  right  angles  to  the  horizontal 
plane  of  the  recumbent  body  ;  c  B,  drawn  at  right 
angles  from  a  c  to  a  b,  where  it  touches  the  top  of  the 
trochanter.  The  line  c  B,  the  base  of  the  triangle,  is  the 
test  line  for  fracture  of  the  neck  ;  in  the  normal  con- 
dition it  will,  in  an  adult,  measure  about  two  and  a 
half  inches  ;  in  cases  of  fracture,  when  the  trochanter 
is  drawn  up  (represented  by  the  dotted  line  in  Fig.  10), 
it  will  become  shortened,  and  measure  about  an  inch 
less  on  the  injured  than  on  the  sound  side  of  the  body. 
F— 21 


66  Manual  of  Surgery. 

(c)  3Iorris's  hi-trochanteric  or  transverse  measure- 
ment "  consists  in  measuring  the  distance  from  the 
median  line  of  the  body  to  the  antero-posterior  line  at 
right  angles  to  the  long  axis  of  the  body,  through 
the  top  of  the  trochanter  on  each  side.  The  distance 
is  always  less  on  the  side  of  the  fracture." 

3.  Crepitus,  sometimes  indistinct,  but  usually  per- 
ceptible on  drawing  down  the  limb  and  rotating  it  in- 
wards, so  as  to  bring  the  fragments  in  apposition. 

4.  Pain  on  pressure  and  especially  on  the  move- 
ment of  rotation. 

5.  More  or  less  sweJlitig  about  the  joint  especially 
in  the  groin,  but  usually  without  any  evidence  of 
bruising. 

6.  Shortening  of  the  limb,  varying  from  half  to  two 
and  a  half  inches.  In  some  cases  this  symptom  is 
absent  at  first,  only  showing  itself  after  an  interval  of 
a  few  days  ;  under  these  circumstances  it  is  probably 
due  to  the  fact  that  the  periosteum  and  reflection  of  the 
capsule,  which  invest  the  neck,  remained  untom  at  the 
time  of  the  accident,  but  subsequently  gave  way  as  the 
result  of  some  movement  of  the  fragments,  or  owing 
to  inflammatory  softening  of  their  structure  ;  or  the 
fragments,  which  were  originally  impacted,  may  have 
become  loosened  and  separated. 

7.  Eversion  of  the  limb,  the  result  partly  of  mus- 
cular action,  but  mainly  of  the  weight  of  the  leg, 
which  causes  it  to  fall  or  roll  outwards  ;  in  exceptional 
cases  the  limb  is  found  to  be  inverted. 

8.  Loss  of  power  in  the  limb,  which  is  usually  com- 
plete. Occasionally,  when  the  periosteum  and  reflection 
of  the  capsule  which  invest  the  neck  of  the  bone  are 
untorn,  the  patient  may  be  able  to  raise  the  limb  and 
even  stand  or  walk  about,  though  with  considerable 
pain  and  difiiculty. 

Union  in  this  fracture  is,  as  a  rule,  simply  fibrous, 
or  it  does  not  occur   at  all,  a   false  joint   forming 


Fractures  of  the  Femur,  67 

between  the  ends  of  the  bone ;  in  most  cases, 
osseous  union  only  occurs  if  impaction  is  present. 
This  result  is  probably  owing  to  the  following  causes : 
1.  The  difficulty  of  keeping  the  fragments  in  perfect 
apposition  and  in  a  state  of  complete  rest.  2.  The 
presence  of  the  synovial  fluid  between  the  fragments. 
3.  The  small  supply  of  blood  to  the  upper  fragment, 
viz.  only  through  the  ligamentum  teres.  The  age  and 
feebleness  of  the  patient,  and  the  atrophy  and  im- 
paired nutrition  of  the  neck  of  the  bone  may  also  con- 
duce towards  the  same  result. 

In  the  impacted  fracture,  which  is  much  less 
common,  the  lower  fragment  is  usually  driven  into  the 
upper  one,  i.e.  the  neck  of  the  bone  is  driven  into  the 
head. 

The  symptoms  are  not  so  well  marked ;  there  is 
less  eversion  and  less  loss  of  power  in  the  limb,  so  that 
the  patient  sometimes  stands  or  walks,  though  with 
difficulty ;  crepitus  is  absent,  and  the  shortening, 
which  is  present  to  the  extent  of  ^  to  1  inch,  cannot  be 
made  to  disappear  on  extension,  unless  the  impaction 
is  broken  down  and  the  fragments  separated. 

Union  in  this  fracture  usually  takes  place  by 
osseous  tissue,  and  the  deformity  is  in  most  cases 
permanent. 

Extracapsular  fracture  of  the  neck  of  the 
femur  is  usually  the  result  of  direct  violence,  and  though 
it  may  occur  at  any  age,  is  most  frequently  met  with  in 
males  under  fifty  years  of  age,  i.e.  during  middle  life. 
The  bone  is  broken  at,  or  just  outside,  the  line  of  inser- 
tion of  its  capsular  ligament,  and  in  most  cases  more  or 
less  splintering  of  the  great  trochanter  is  present,  for 
the  same  force  that  causes  the  fracture  also  drives 
the  neck  of  the  bone  into  the  cancellous  tissue  at  the 
base  of  the  trochanter  and  breaks  it  into  frai^ments. 
The  fractui'e  may  be  either  impacted  or  non-impacted, 
the  former  beinj;  most  common,    for  the  neck  verv 


68  Manual  op  Surgery. 

frequently  remains  firmly  wedged  into  tlie  trochanter 
and  osseous  tissue  at  the  base  of  the  neck.  Owing  to  the 
fact  that  the  fracture  is  generally  the  result  of  direct 
violence,  e,g.  a  fall  on  the  hip,  considerable  bruising 
and  swelling  of  the  soft  parts  is  usually  present  about 
the  joint. 

In  the  non-imjmcted  variety,  crepitus  is  very  dis- 
tinct,  and  can  be  readily  felt  on  laying  the  hand  over 
the  trochanter,  especially  if  the  limb  is  rotated  at  the 
same  time  ;  shortening  is  present  to  the  extent  of  from 
1  to  2|^  inches,  but  can  be  made  to  disappear  on 
making  extension  on  the  leg  ;  the  limb  is  everted. 

In  the  impacted  variety,  crepitus  is  absent,  unless 
considerable  force  is  used  and  the  fragments  are  sepa- 
rated ;  shortening  is  present,  but  does  not  usually 
exceed  an  inch,  and  cannot  be  made  to  disappear  on 
making  extension,  unless  the  impaction  is  broken 
down ;  the  limb  is  almost  always  everted  ;  there  is  less 
loss  of  power  about  the  hip,  the  patient  being  some- 
times able  to  stand,  or  even  walk,  though  with  consi- 
derable pain  and  difficulty. 

Diag^uosis. — An  impacted  fracture  differs  from  a 
non-impacted  in  the  following  points  :  1.  Crepitus  is 
absent.  2.  Shortening  is  usually  less  marked,  and 
does  not  disappear  on  traction  unless  the  fragments  are 
separated.  3.  There  is  less  loss  of  power  in  the  limb, 
and  the  patient  can  often  raise  it,  and  even  stand  or 
walk,  though  with  difficulty.  4.  Evidence  of  direct 
injury  to  the  soft  parts  about  the  hip  is  more  commonly 
present.  5.  Inversion  of  the  limb,  though  rare,  is  more 
common  in  the  impacted  than  in  the  non-impacted 
variety. 

Severe  contusions  of  the  hip,  when  accompanied  by 
e version  and  loss  of  power  in  the  limb,  may  at  first 
sight  simulate  very  closely  a  fracture  of  the  neck  of  the 
femur ;  but  the  presence  of  shortening,  the  altered 
position  of  the  great  trochanter,  and  the  presence  of 


Fractures  of  the  Femur.  69 

crepitus  (unless  impaction  has  taken  place),  will 
usually  distinguish  a  fracture  from  a  contusion.  In 
exceptional  cases  and  especially  when  occurring  in  old 
persons,  a  contusion  of  the  hip  may  be  followed  after  a 
time  by  interstitial  absorption  of  the  neck  of  the  femur, 
and  under  these  circumstances  slight  shortening  of  the 
limb  may  gradually  be  produced. 

When  a  person,  the  subject  of  chronic  rheumatic 
arthritis  of  the  hip,  receives  an  injury  to  the  parts  about 
the  jcint,  the  shortening  of  the  limb^  which  often  exists, 
and  the  presence  of  crepitus  from  the  rubbing  together 
of  osteophytes,  may  cause  the  condition  to  simulate 
fracture  of  the  neck  of  the  bone.  The  history,  how- 
ever, of  the  case,  the  fact  that  other  joints  are  frequently 
affected,  and  that  the  patient  suffered  from  pain  and 
stiffness  about  the  hip,  with  possibly  some  shortening 
of  the  limb  prior  to  the  accident,  wUl  usually  serve  to 
distinguish  the  true  nature  of  the  injury. 

From  a  dislocation  of  the  hip  a  non-impacted  frac- 
ture may  be  distinguished  by  the  presence  of  crepitus, 
the  mobility  of  the  limb,  and  the  fact  that  the  head  of 
the  bone  cannot  be  detected  in  any  of  the  situations  in 
which  it  would  be  found  in  that  injury.  In  impacted 
fracture  with  inversion  of  the  limb,  the  injury  may  be 
confounded  with  a  dorsal  or  sciatic  dislocation  of  the 
femur,  as  there  is  an  absence  of  crepitus,  the  move- 
ments of  the  joint  are  restrained,  and  the  position  of 
the  leg  is  somewhat  similar.  The  absence  of  the  head 
of  the  bone  from  the  dorsum  ilii  or  sciatic  notch,  and 
the  free  movement  of  the  limb,  especially  under 
anaesthesia,  will,  however,  usually  distinguish  a  frac- 
ture. 

Separation  of  tlie  upper  epiphysis  of  the 
femur,  which  lies  completely  within  the  joint,  has  been 
described,  but  is  of  somewhat  doubtful  occurrence. 

Treatment. — In  non-imjmcted  intracapsidar  frac- 
ture   an    attempt    should    be    made    to    bring    the 


70  Manual  of  Surgery. 

fragments  into  apposition,  and  to  maintain  them  so, 
in  the  hope  that  osseous  union  will  occur.  To  eflfect 
this,  extension  should  be  applied  to  the  limb  by 
means  of  a  weight,  in  the  way  described  in  cases  of 
fracture  through  the  shaft  (page  72)  ;  the  patient 
should  be  kept  in  bed  for  six  or  eight  weeks,  and 
some  form  of  support  or  stiff  bandage  afterwards 
worn  for  about  the  same  period.  As,  however,  this 
injury  is  usually  met  with  in  old  persons,  v>^ho  in 
many  cases  will  not  bear  long  confinement  in  the 
recumbent  position,  owing  to  a  tendency  to  the  for- 
mation of  bed-sores  or  the  supervention  of  hypostatic 
pneumonia,  it  will  often  be  necessary  after  two  or 
three  weeks,  or  even  less,  to  allow  them  to  get  about 
on  crutches,  wearing  either  a  stiff  bandage  or  a 
Thomas's  splint,  such  as  is  often  used  in  cases  of 
morbus  coxae ;  under  these  circumstances  the  union 
will  probably  be  fibrous,  and  the  patient  will  in  con- 
sequence be  left  with  a  weak  or  shortened  limb,  more 
or  less  lame  for  the  remainder  of  life.  Some 
surgeons,  instead  of  employing  any  special  apparatus, 
simply  support  the  limb  on  pillows,  or  between  sand- 
bags ;  others,  again,  make  use  of  the  double  inclined 
plane. 

In  non-iTTipacted  extracapsular  fracture,  extension 
by  means  of  a  weight  (page  72)  should  always  be 
employed,  and  in  cases  where  there  is  much  splinter- 
ing of  the  ends  of  the  bone,  a  bandage  round  the 
hips  will  often  be  found  useful  in  keeping  the  fragments 
in  apposition.  Firm  osseous  union  will  almost  always 
take  place. 

In  impacted  fractures  of  the  neck  no  attempt  should 
be  made  (especially  in  the  intracapsular)  to  loosen 
the  fragments  and  restore  the  limb  to  its  proper  length. 
Osseous  union  generally  results,  even  in  old  j^eople, 
but  the  limb  is  left  permanently  shortened,  and  usually 
somewhat  everted.     All  that  is  necessary  is  to  keep 


Fracturf.s  of  the  Femur.  71 

the  part  at  rest  by  means  of  a  long  outside  splint, 
no  extension  being  required,  unless  with  the  object 
of  kee^nng  the  limb  level  and  parallel  with  its  fel- 
low. 

Great  troclia.ntcr. — Separation  of  the  great 
trochanter  is  met  with  as  an  independent  injury, 
and  also  as  a  complication  of  extracapsular  fracture. 
When  occurring  by  itself,  the  sym])toms  of  this  injury 
are  mobility  of  the  trochanter,  with  crepitus,  which 
is  usually  distinct,  unless  the  trochanter  is  drawn 
upwards  and  backwards  on  to  the  dorsum  ilii,  where  it 
may  form  a  distinct  projection  ;  more  or  less  pain  and 
swelling  are  present  about  the  hip,  as  the  fracture  is 
always  the  result  of  direct  violence.  If  accompanied 
by  fracture  of  tlie  neck  of  the  femur,  evidence  of  that 
injury  will  also  be  present. 

Separation  of  the  epiphysis  of  the  great  trochan- 
ter is  rarely  met  with. 

Treatment. — A  bandage  round  the  hip,  or  some 
form  of  cap  moulded  to  the  part,  will  generally  be 
found  useful  in  keeping  the  fragment  in  position  ;  the 
limb  should  also  be  kept  at  rest  by  means  of  a  long 
outside  splint. 

Shalt. — The  shaft  of  the  femur  may  be  fractured 
at  any  part  of  its  course,  its  middle  third  at  a  variable 
level  being  the  commonest  situation.  The  line  of 
fracture  may  be  either  transverse  or  oblique,  and,  in 
exceptional  cases,  longitudinal  and  almost  parallel 
with  the  long  axis  of  the  bone,  or  even  of  a  spiral 
nature.  The  injury,  which  is  usually  the  result  of 
indirect  violence,  is  accompanied  by  well-marked 
symptoms  ;  there  is,  as  a  rule,  considerable  shortening 
with  e  version  of  the  limb,  loss  of  power,  increased 
mobility,  and  crepitus ;  more  or  less  deformity,  due 
to  the  displacement  of  the  fragments,  is  usually  pre- 
sent. 

In  tlie  upper  third,  where  the  line  of  fracture  i^ 


72 


Manual  of  Surgery. 


often  oblique,  the  upper  fragment  is  drawn  forwards 
and  outwards,  and  also  everted,  while  the  lower  one 
is  drawn  upwards  and  inwards,  so  that  its  fractured 
end  lies  above,  behind,  and  to  the  inner  side  of  that 
of  the  upi)er  one ;  rotation  outwards  of  the  lower 
fragment  is  almost  always  present. 

In  the  middle  third  the  displacement  is  often 
much  the  same,  though  it  will  vary  somewhat  with 
the  obliquity  of  the  fracture. 

In  the  lower  third  the  uj^per  fragment  is  drawn 
slightly  forwards  and  inwards,  the  lower  one  upwards 


Fig.  11. — Extension  by  Weight. 


and  backwards,  behind  the  lower  end  of  the  upper 
fragment. 

Treatment. — Fracture  through  the  shaft  of  the 
femur  may  be  treated  in  many  different  ways. 

Extension  by  a  weight  (Fig.  11)  is  a  plan  very 
universally  adojDted  at  the  present  day.  A  long  strip 
of  plaister  is  applied  to  each  side  of  the  leg  as  high  as 
the  knee,  a  loop  being  left  beneath  the  sole  of  the 
foot ;  it  is  kept  in  ])lace  by  short  pieces  of  strapping 
which  encircle  the  leg  transversely,  and  over  these  a 
bandage  should  be  carried  from  the  toes  up  to  the 
knee,  in  order  to  fix  the  strapping  and  at  the  same 
time  prevent  any  swelling  of  tlie  foot.  To  prevent 
the  strapping  from  chafing  tlie  skin,  a  thin  flannel  or 
domette  bandage  may  be  first  applied  to  the  limb  be- 
neath it.  To  obtain  a  firmer  hold  on  the  limb,  some  sur- 
geons carry  the  longitudinal  strips  of  strapping  above 


Fractures  of  the  Femur.  73 

the  knee,  but  not  so  high  as  the  seat  of  fracture  :  to 
fix  them,  several  turns  of  a  bandage,  or  one  or  two 
pieces  of  strapping  (not  applied  too  tightly),  are  then 
carried  round  the  lower  part  of  the  thigli,  just  above 
the  patella.  By  this  means  there  is  less  chance  of 
the  strapping  slipping,  and  as  extension  is  made  from 
the  lower  part  of  the  thigh  as  well  as  from  the  leg, 
there  is  less  strain  on  the  knee  than  if  extension  is 
made  from  the  leg  alone. 

A  piece  of  wood  (in  length  from  one  to  two 
inches  greater  than  the  distance  between  the  mal- 
leoli) should  be  fixed  transversely  in  the  loop 
left  beneath  the  sole,  so  as  to  form  a  kind  of 
stirrup,  and  take  off  all  pressure  from  the  sides  of 
the  foot  and  ankle.  A  strong  cord  is  fastened  by  one 
end  to  the  centre  of  the  stirrup,  and  carried  over  a 
pulley  arranged  at  the  foot  of  the  bed.  A  weight, 
varying  in  an  adult  from  five  to  twelve  pounds  or 
more,  is  attached  to  the  other  end  of  the  cord  ;  this, 
if  it  acts  in  a  line  with  the  axis  of  the  limb,  will  make 
extension  on  the  lower  fragment,  and  thus  overcome 
the  contraction  of  the  muscles,  which  tend  to  draw  it 
upwards.  Counter-extension  may  be  made  by  a 
perineal  band  attached  above  to  the  head  of  the  bed, 
but  in  most  cases  the  weight  of  the  patient's  body 
will  be  sufficient,  if  the  foot  of  the  bed  is  slightly 
raised.  To  steady  the  limb,  a  long,  straight,  outside 
splint  should  be  applied,  reaching  from  the  side  of  the 
chest  to  the  foot,  and  three  short  splints,  fixed  by 
means  of  straps  (so  they  are  readily  removable  for  the 
purpose  of  examining  the  fracture)  to  the  front,  back, 
and  inside  of  the  thigh,  will  also  be  useful  in  assisting 
to  maintain  the  fragments  in  position.  The  tendency 
to  eversion  of  the  limb  should  be  prevented,  either  by 
fixing  a  horizontal  cross  bar  to  the  lov^^er  end  of  the 
long  splint,  or  by  laying  a  sand-bag  along  its  outei 
side. 


74  Manual  of  Surgery. 

Elastic  extension  is  a  modification  of  the  preced- 
ing method ;  one  end  of  a  piece  of  strong  indiarubl^er 
tubing  being  attached  to  the  stirrup,  the  other  end  to 
the  lower  extremity  of  a  Liston's  long  splint,  counter- 
extension  being  made  by  a  perineal  band,  as  in  the 
manner  next  described. 

Liston's  long  splint  and  perineal  band  (Fig.  12)  is 
much  less  frequently  used  at  the  present  time  than 
it  was  some  years  ago.  A  long,  straight  splint, 
notched  at  its  lower  end,  and  reaching  from  the  axilla 
to  about  four  inches  below  the  sole,  is  first  fixed  to  the 
foot    and    ankle    by    a    figure  of   8  bandage,  which 


Fig.  12. — Liston's  Long  Splint. 

]>asses  through  the  notches  at  its  lower  extremity. 
The  fragments  having  been  brought  into  position  by 
traction  on  the  leg  and  splint,  counter-extension  is 
made  by  means  of  a  perineal  band,  i.e.  a  well-padded 
bandage,  which  passes  in  front  of  the  gi'oin  and  behind 
the  buttock,  and  the  ends  of  which  are  passed  through 
two  holes  at  the  upj^er  end  of  the  splint,  where  they 
are  securely  tied  and  tightened  up  from  time  to  time, 
as  the  bandage  becomes  slackened. 

This  method  has  several  disadvantages  as  com- 
pared with  extension  by  a  weight,  for  the  pressure  of 
the  perineal  band  is  very  liable  to  produce  excoriation 
of  the  skin,  and  its  a[)plication  is  often  painful. 
Traction  being  made  merely  from  the  foot  and  ankle, 
considerable  pressure  is  exerted  upon  those  parts,  and 
at  the  same  time  the  foot  becomes  extended,  so  that 


Fractures  of  the  Femur. 


75 


not  only  is  the  position  irksome,  but  it  is  often  fol- 
lowed by  stiffness  and  weakness  of  the  ankle  joint  from 
stretching  of  its  anterior  ligament.  When  a  weight  is 
employed  the  perineal  band  is  not  required,  extension 
is  made  from  each  side  of  the  leg,  and  the  foot  remains 
at  a  right  angle  with  the  leg,  in  a  position  which  is 
comfortable  for  the  patient,  and  not  likely  to  be  fol- 
lowed by  stiffness  of  the  joint. 

Desault's  long  splint  differs  from  Liston's  in  the 
fact  that  its  lower  extremity,  instead  of  being  notched, 
has  a  lateral  focft  piece. 

Vertical  extension  (Fig.  13),  recommended  by 
Bryant,  is  very  useful  in  the 
case  of  young  children,  where  it 
is  always  difficult  to  keep  the 
apparatus  employed  free  from 
contact  with  urine  and  fseces. 
In  this  method,  both  limbs  are 
swung  at  a  right  angle  to  the 
trunk  from  a  bar  fixed  over  the 
bed,  the  weight  of  the  body  act- 
ing as  a  counter-extending  force. 

A  Macintyre's  splint  (Fig. 
14),  or  the  double  inclined 
plane,  will  often  be  found  use- 
ful in  fracture  through  the  upper 
third  of  the  shaft,  where  the 
upper  fragment  is  tilted  for- 
wards ;  and  again  in  fracture 
through  the  lower  third,  where 
the  lower  fragment  is  drawn 
backwards. 

Another  plan  of  treatment, 
sometimes   adopted   under  similar  circumstances,  con- 
sists in    flexing  the  thigh  upon  the  trunk  almost  to  a 
right  angle,  and  the  leg  upon  the  thigh ;  the  limb  is 
then  laid  on  its  outer  side  on  an  angular  splint,  which 


13. — Vertical  Suspen- 
sion of  Femur. 


76  Manual  of  Surgery. 

reaches  from  the  hip  to  the  ankle,  and  several  shoii; 
splints  are  also  applied  round  the  thigh. 

Erich  sen  advocates  putting  up  the  limb  at  once  in 
some  immovable  apparatus,  e.g.  a  starch  bandage  with 
a  thick  layer  of  cotton  wadding  beneath  ;  this  should  be 
cut  up  and  trimmed  on  the  second  or  third  day,  and  then 
re-applied.  The  advantage  of  this  method  is  that  the 
patient  may  leave  his  bed  and  get  about  on  crutchas 
after  three  or  four  days. 

Space  prevents  more  than  a  brief  reference  to 
the  numerous  other  plans  of  treating  this  fracture,  viz.  : 

Nathan  Smith's  anterior  splint,  a  wire  splint 
applied   to  the  front  of  the   leg  and  thigh,  reaching 


Fig.  14.— Macintyre's  Splint. 

from  the  foot  to  the  groin,  and  by  means  of  whicli  the 
limb  is  swung. 

Hodgen's  splint,  where  the  limb  is  supported  on  a 
cradle  composed  of  cotton  sacking  attached  to  two 
lateral  bars  of  strong  wire,  wdiich  reach  from  the  upper 
part  of  the  thigh  to  beyond  the  foot ;  the  cradle  is 
swung  from  an  upright  post  at  the  foot  of  the  bed,  and 
traction  is  made  upon  the  cradle,  which,  in  its  turn, 
makes  extension  on  the  leg  by  means  of  strapping 
attaching  the  leg  to  the  lower  cross  bar  of  the  cradle, 
which  projects  for  some  inches  beyond  the  sole  of  the 
foot. 

Thomas's  splint,  one  sijnilar  to  that  used  in  cases 
of  disease  of  the  knee  joint  being  sometimes  employed, 
along  with  four  short  splints  round  the  thigh  itself. 

Hammond's  double  splint,  consisting  of  two  long 


Fractures  of  the  Femur,  ii 

straight  splints,  applied  to  the  outside  of  both  limbs, 
and  connected  bj  a  cross  bar  below  the  feet. 

Bryant's  double  splint,  similar  to  that  employed  in 
cases  of  disease  or  excision  of  the  hip. 

In  fracture  through  the  shaft,  union  is  generally 
ejSected  in  about  eight  weeks  in  the  case  of  adults,  but 
it  is,  as  a  rule,  advisable  to  wear  some  form  of  stiff 
bandage  for  at  least  twelve  weeks.  In  many  instances 
some  slight  shortening  of  the  limb  will  remain,  even 
after  the  most  careful  treatment. 

L«OM  er  exti'emity. — Fracture  through  the  lower 
end  of  the  femur  may  be  supracondyloid,  i.e.  just 
above  the  condyles  and  not  involving  the  knee  joint. 
The  symptoms  are  very  similar  to  those  of  fracture 
through  the  lower  third  of  the  shaft,  the  lower 
fragment  being  drawn  backwards  by  the  gastrocnemius, 
so  that  its  fractured  end  forms  a  projection  at  the 
upper  part  of  the  popliteal  space. 

Very  frequently  the  joint  is  involved,  the  line  of 
fracture  being  oblique,  and  running  across  either 
condyle,  or  through  the  intercondyloid  space ;  or  it 
may  be  T-shaped,  running  transversely  above  the 
condyles  and  also  between  them  into  the  joint.  Under 
these  circumstances  considerable  swelling  of  the 
joint  is  usually  present,  owing  to  effusion  of  blood  and 
fluid  into  its  interior  ;  crepitus  and  abnormal  mobility 
can  be  readily  detected  on  moving  the  joint,  or  upon 
grasping  the  condyles  and  mo\'ing  them  upon  one 
another  j  when  the  condyles  are  separated,  some  in- 
crease in  the  breadth  of  the  lower  end  of  the  femur  is 
often  apparent ;  in  addition  there  will  be  pain,  loss  of 
power,  etc.,  in  the  limb. 

Separation  of  the  lower  epiphysis  is  sometimes 
met  with  in  young  subjects ;  the  symptoms  are  identi- 
cal with  those  of  supracondyloid  fracture,  except  that 
crepitus  is  less  distinct  or  absent,  owing  to  the 
•smoother   nature   of   the    surface   of    the   fragments. 


78  Manual  of  Surgery. 

Tliis  injurj  is  liable  to  be  followed  by  some  arrest  in 
the  growth  of  the  lower  end  of  the  femur. 

Treatment.  —  In  siipracondyloid  fracture,  or  in 
separation  of  the  epiphysis,  when  the  lower  fragment 
is  drawn  backwards,  the  double  inclined  plane^  or  a 
Macintyre's  splint,  will  be  found  useful ;  when  the 
deformity  cannot  be  overcome  by  flexing  the  knee  in 
this  way,  division  of  the  tendo  Achillis,  as  recommended 
by  Bryant,  may  be  required  in  order  to  relax  the 
gastrocnemius,  the  limb  being  afterwards  put  up  in 
the  same  manner,  or  with  extension  by  a  weight,  as  in 
fracture  through  the  shaft. 

In  cases  of  fracture  through  the  condyles  involving 
the  knee  joint,  the  limb  should  be  fixed  on  a  straight 
back  splint,  and  the  accompanying  synovitis  treated 
with  some  cooling  lotion ;  lateral  pressure,  by  means 
of  side  splints,  will  often  assist  in  keeping  the  frag- 
ments in  apposition.  Passive  movement  should  be 
commenced  in  about  six  weeks,  otherwise  considerable 
stiffness  of  the  joint  will  probably  result. 

In  cases  of  compound  fracture  involving  the  knee 
joint,  amputation  will  often  be  required  ;  the  surgeon 
must,  however,  be  guided  by  the  age  and  general  con- 
dition of  the  patient,  as  well  as  by  the  severity  of  the 
local  injury. 

The  Patella. 

Fractures  of  the  patella  may  be  transverse,  oblique, 
vertical,  or  star-shaped,  and  comminuted. 

Transverse  fracture,  the  commonest  variety,  is 
generally  the  result  of  muscular  action,  the  bone  being 
snapped  across  the  condyles  of  the  femur  by  a  sudden 
and  forcible  contraction  of  the  quadriceps  extensor, 
when  the  knee  is  bent,  as  during  an  attempt  to  save 
the  body  from  falling  backwards ;  in  many  cases  the 
line  of  fracture  is  not  directly  transverse,  but  some- 
wliat  oblique. 


PRACTURES    OF    THE   PATELIA.  79 

Vertical  and  comminuted  fractures  are  always  due 
to  direct  violence,  e.g.  a  fall  or  blow  upon  the  knee. 

Syniptonis. — In  transverse  and  slightly  oblique 
fracture  there  is  usually  more  or  less  separation  of 
the  fragments,  increased  on  bending  the  knee,  the 
vipper  one  being  drawn  away  from  the  lower  by  the 
muscles  attached  to  it ;  if  seen  directly  after  the 
accident,  a  distinct  gap  or  depression  will  often  be 
found  in  front  of  the  joint  between  the  fragments,  and 
at  the  bottom  of  this  the  condyles  of  the  femur  can 
sometimes  be  felt.  There  is  inability  to  stand  and 
extend  or  raise  the  leg  ;  crepitus  cannot  be  distin- 
guished unless  the  upper  fragment  is  drawn  down  and 
brought  into  apposition  with  the  lower  one.  If  some 
hours  have  elapsed,  an  effusion  of  blood  (heemarthrosis) 
or  synovial  fluid,  or  a  mixture  of  both,  takes  place 
into  the  interior  of  the  joint,  which  becomes  swollen 
and  distended,  and  under  these  circumstances  the 
depression  between  the  two  fragments,  which  become 
more  widely  separated,  disappears,  and  may  be  replaced 
by  a  distinct  bulging  ;  at  the  same  time  the  joint 
becomes  more  or  less  hot  and  inflamed,  and  evidence 
of  synovitis  appears.  In  exceptional  cases,  where  there 
is  no  laceration  of  the  periosteum  and  fibrous  tissue 
investing  and  overlying  the  patella,  separation  of  the 
fragments  may  not  occur. 

In  vertical  and  comminuted  fractures  there  is 
usually  little  separation  of  the  fragments,  and  under 
these  circumstances  crepitus  can  be  readily  detected. 

Mode  of  union. — In  vertical  and  comminuted 
fractures,  and  in  transverse,  when,  owing  to  the  peri- 
osteum remaining  untorn,  there  is  little  or  no  separation 
of  the  fragments,  osseous  union  as  a  rule  readily  takes 
place. 

In  most  cases,  however,  of  transverse  fracture, 
difficulty  is  experienced  in  keeping  the  fragments  in 
immediate  apposition,  for  one  or  more  of  the  following 


8o  Manual  of  Surgery, 

reasons;  viz.  1.  The  contraction  of  the  quadriceps 
extensor  drawing  away  the  upper  fragment.*  2. 
Accumulation  of  fluid  (blood  or  synovial)  in  the  joint, 
distending  it  and  consequently  tending  to  separate  the 
fragments.  (That  this  is  so,  is  proved  by  the  fact  that 
the  difficulty  in  approximating  them  is  usually  in  pro- 
portion to  the  amount  of  swelling.)  3.  Interposition 
of  blood  clot,  or  of  the  fibrous  and  aponeurotic  struc- 
tures which  overlie  the  patella,  between  the  frag- 
ments. 

The  result  is  that  union  is  generally  effected  by 
fibrous  tissue,  and  as  this  usually  tends  to  yield  and 
stretch,  the  fragments  of  bone  become,  after  a  time, 
separated  from  one  another,  often  to  the  extent  of 
several  inches,  so  that  a  weakened,  and  in  some  cases 
a  more  or  less  useless,  limb  remains.  In  exceptional 
cases,  even  when  the  fracture  is  treated  in  the  ordinary 
way  by  means  of  splints,  true  osseous  union  is  said  to 
occur ;  but  this  result  is  extremely  rare  unless  the 
joint  is  opened  and  the  fragments  wired  together  in 
the  way  described. 

Treatoieiit. — In  vei-tical  and  comminuted  frac- 
tures, where  there  is  not  usually  much,  or  any,  separation 
of  the  fragments,  the  limb  should  be  kept  on  a  straight 
back  splint,  and  some  cooling  lotion  applied  over  the 
knee. 

In  transverse  fi'acture,  where  the  fragments  are 
generally  widely  separated,  some  means  must  be  taken 
to  bring  them  into  apposition  and  to  maintain  them 
so,  in  the  hope  that  close  fibrous,  if  not  osseous,  union 
will  result. 

The  leg  should  be  extended  on  the  thigh,  and  the 
thigh   fl.exed  on  the  trunk,  by  means  of  a  long  back 

*  According  to  INIr.  J.  Hutchinson,  spasm  of  the  muscles  only 
causes  separation  at  the  moment  of  the  accident ;  as  soon  as  the 
limb  is  at  rest  in  bed.  its  agency  ends  {Brit.  Med.  Journal, 
Nov.  10,  1881). 


Fractures  of  the  Patella.  8i 

splint  with  a  foot  piece,  the  lower  end  of  which  is 
raised,  in  order  to  relax  the  rectus  muscle,  which,  if  it 
remains  contracted,  •  helps  to  draw  away  the  upper 
fragment.  Some  surgeons,  on  the  other  hand,  keep  the 
limb  in  a  horizontal  position,  believing  that  the  muscle 
soon  becomes  relaxed  and  ceases  to  act. 

If  seen  immediately  after  the  accident,  and  before 
any  effusion  has  taken  place,  the  fracture  may  be  put 
up  at  once ;  if,  however,  some  interval  has  elapsed 
and  the  joint  has  become  swollen  and  painful,  the 
necessary  pressure  could  not  at  once  be  borne.  Under 
these  circumstances  an  ice  bag  or  an  evaporating  lotion 
should  be  applied  to  the  knee,  and  then  in  the  course 
of  a  few  days,  when  the  inflammatory  symptoms  have 
subsided,  some  means  must  be  adopted  to  bring  the 
fragments  into  apposition. 

The  usual  plan  is  to  draw  down  the  upper  frag- 
ment by  a  broad  strip  of  strapping,  carried  across  the 
limb  just  above  it,  and  then  diagonally  downwards 
and  forwards  round  the  splint ;  a  pad  of  lint  should 
be  interposed  between  the  strapping  and  the  limb 
above  the  upper  fragment,  so  as  to  assist  in  pressing 
it  downwards  and  at  the  same  time  prevent  ulceration 
of  the  skin  from  the  pressure  of  the  strapping  directly 
upon  it.  Another  strip  of  strapping  should  be  then 
carried  in  the  reverse  direction  round  the  lower  frasr- 
ment  and  splint,  and  in  this  way  the  two  fragments 
can  generally  be  brought  into  apposition  with  one 
another. 

To  fix  the  strapping,  a  figure  of  8  bandage 
should  be  carried  above  and  below  the  knee,  and  to 
prevent  both  bandage  and  strapping  from  slipping, 
notches  may  be  cut,  or  two  nails  fixed,  on  either  side 
of  the  splint  above  and  below  the  centre  of  the  joint. 
In  cases  where  the  edges  of  the  fragments  tilt  for- 
wards and  tend  to  separate,  a  third  piece  of  strapping, 
carried  transversely  round  the  limb,  directly  over  the 
G— 21 


82  Manual  of  Surgery. 

fragments,  witli  a  pad  of  lint  intervening,  will  some- 
times be  fouixi  useful. 

The  splint  should  be  kept  applied  for  six  to  ei-ght 
"weeks ;  at  the  end  of  this  period  it  may  be  left  off, 
and  the  patient  allowed  to  get  about  on  crutches, 
wearing  a  stiff  bandage  to  prevent  any  flexion  of  the 
joint.  This  should  be  worn  for  from  three  to  six 
months  ;  and  then,  if  firm  union  appears  to  have  taken 
place,  tJie  patient  may  begin  to  very  gradually  bend 
the  knee.  In  most  cases,  however,  the  knee  will  be 
left  more  or  less  permanently  weakened,  as  the  uniting 
medium,  which  is  usually  fibrous,  generally  tends  to 
yield ;  under  these  circumstances,  if  a  leather  knee- 
cap is  worn,  it  will  afford  considerable  support,  and 
materially  increase  the  usefulness  of  the  limb. 

Many  other  plans  of  treatment  may  be  adopted  with 
the  object  of  bringing  the  fragments  into  apposition  ; 
instead  of  ordinary  strapping,  indiarubber  bands  are 
sometimes  used ;  leather  straps  may  be  passed  trans- 
versely round  the  limb  above  and  below  the  fragments, 
and  then  approximated  by  means  of  longitudinal  straps; 
a  piece  of  strapping  may  be  fixed  round  the  limb  above 
the  upper  fragment,  and  traction  downwards  made 
upon  it,  by  means  of  elastic  extension,  or  by  a  cord 
and  weight  susj)ended  over  a  pulley  at  the  bottom  of 
the  bed. 

Another  method  consists  in  applying  a  long  strip 
of  strapping  to  the  front  of  the  limb,  and  fixing  it  by 
transverse  slips  and  a  bandage,  a  loop  being  left  free 
over  the  knee;  pads  of  lint  are  placed  beneath  the 
sti-apping,  above  and  below  the  fragments  of  the 
patella.  A  piece  of  stick  is  passed  through  the  loop, 
which  is  then  twisted  up  until  the  fragments  are 
drawn  into  apposition. 

Malgaigne's  hooks  are  not  often  employed  at  the 
present  day,  on  account  of  the  pain  and  irritation, 
with    a  tendency  to   suppuration,    which    they  often 


Fractures  of  the  Patella,  83 

produce.  They  consist  of  a  paii-  of  double  hooks,  which 
are  passed  through  the  skin,  fixed  in  the  two  frag- 
ments, and  then  approximated  by  means  of  a  screw 
worked  with  a  key.  A  modification  of  this  plan  is, 
however,  sometimes  adopted,  the  hooks  being  fixed 
into  pieces  of  strapping  passed  roimd  the  limb  above 
and  below  the  fragments,  instead  of  into  the  skin  and 
bone  itseLf. 

Some  surgeons  put  up  the  limb  at  once,  or  as  soon 
as  the  swelling  has  subsided,  in  a  stiff  bandage,  the 
fragments  having  been  first  brought  together  by  strips 
of  strapping  in  the  way  described.  The  advantage  of 
this  method  is  that  it  does  not  necessitate  confine- 
ment to  bed^  the  patient  being  able  to  get  about 
on  crutches  after  a  few  days. 

When  the  joint  is  distended  with  fluid,  another 
plan  consists  in  drawing  off  the  fluid  with  an  as- 
pirator, instead  of  waiting  for  it  to  become  absorbed. 
Care  should  ahvays  be  taken  that  the  instruments 
used  are  perfectly  clean,  and  it  is  advisable  that 
the  operation  should  be  performed  with  careful  anti- 
septic precautions. 

Subcutaneous  division  of  the  insertion  of  the  quad- 
riceps extensor  into  the  patella,  as  well  as  of  the  liga- 
mentum  patellae,  has  also  been  adopted  in  a  few  cases 
Avith  the  object  of  ensuring  perfect  apposition  of  the 
fragments. 

Laying  open  the  joint  and  wiring  the  fragments  has 
recently  been  advocated  by  Sir  Joseph  Lister,"^  and  is 
a  plan  of  treatment  which  has  now  been  adopted  in  a 
large  number  of  cases  with  considerable  success. 

The  operation,  which  should  always  be  carried 
out  under  the  most  careful  antiseptic  precautions,  is 
performed  in  the  following  way  :  A  longitudinal 
incision  is  ma-de  over  the  centre  of  the  joint,  which 
is  opened,  and  the  fragments  of  the  patella  are 
*  Brit.  Med.  Journal,  18S3;  vol.  i.,  p.  855. 


84  Manual  of  Surgery. 

exposed ;  any  blood  clot  which  is  present  in  the 
joint  or  between  the  fragments  is  turned  out,  and 
the  fragments  themselves  are  cleared  of  the  aponeurotic 
and  fibrous  tissue,  which  is  often  found  lying  in  be- 
tween and  over  their  broken  surfaces.  Each  fragment 
is  then  bored  obliquely  with  a  drill,  taking  care  not  to 
reach  its  cartilaginous  surface.  Sutures  of  silver  wire 
are  then  passed  through  the  drill  holes,  and  the  frag- 
ments having  been  drawn  together,  the  ends  of  the 
wire  are  twisted,  cut  short,  and  then  hammered  down 
on  the  bone,  where  they  may  be  allowed  to  remain 
permanently,  without  causing  any  irritation.  Free 
drainage  should  be  provided  for  by  the  insertion  of 
tubes  in  openings  made  at  the  back  of  the  joint  on 
either  side. 

If  all  goes  well,  firm  bony  union  will  result,  and 
the  movements  of  the  joint  will  be  more  or  less  com- 
pletely restored.  The  operation,  however,  is  one 
which  should  not  be  lightly  undertaken,  nor  without 
the  most  careful  antiseptic  precautions ;  it  should 
always  be  borne  in  mind  that  the  usual  plans  of  treat- 
ment, if  carefully  carried  out,  give,  as  a  rule,  very  fair 
results.  Wiring  the  fragments  has  in  several  cases 
been  followed  by  suppuration  in  the  joint,  and,  as  a 
consequence,  the  limb,  and  even  the  patient's  life,  have 
been  lost ;  or  if,  after  this  complication  {i.e.  suppura- 
tion), recovery  has  taken  place,  the  knee  has  been  left 
more  or  less  completely  anchylosed. 

The  operation  is  therefore,  perhaps,  more  applic- 
able for  old  cases  of  fracture,  where,  in  consequence  of 
the  fibrous  tissue,  by  which  union  has  been  effected, 
having  given  way,  the  fragments  have  become  separ- 
ated, and  the  limb  in  consequence  rendered  more  or 
less  useless.  Under  these  circumstances  the  fragments 
should  be  exposed,  and  their  broken  surfaces  refreshed 
and  brought  together  with  silver  sutures  in  the  way 
described. 


Fractures  of  the  Leg.  85 

The  Leg. 

Tibia  and  fibula.— Fractures  of  the  tibia  and 
fibula  are  of  frequent  occurrence,  it  being  more  com- 
mon for  both  bones  to  be  broken  than  for  one  to  be 
fractured  by  itself.  When  due  to  indirect  violence, 
the  most  common  cause  of  fracture  in  this  situation, 
the  tibia  usually  gives  way  at  its  weakest  part,  i.e. 
about  its  lower  third,  and  the  fibula  at  a  slightly 
higher  level ;  when  due  to  direct  violence,  the  bones 
are  broken  at  the  spot  where  the  violence  acts.  In 
some  cases,  and  especially  when  involving  the  upper 
part  of  the  bone,  the  line  of  fracture  is  transverse,  and 
under  these  circumstances  the  displacement  of  the 
fragments  is  often  very  slight.  Much  more  commonly 
the  line  of  fracture  is  oblique  from  above  and  behind 
downwards  and  forwards,  and  from  without  inwards, 
so  that  the  upper  fragment  projects  forwards  beneath 
the  skin  (often  piercing  it  and  rendering  the  fracture 
compound),  the  lower  fragment  being  drawn  upwards 
behind  it  by  the  muscles  of  the  calf. 

The  symptoms  of  this  injury  are  usually  mani- 
fest ;  in  transverse  fracture  there  is  often  very  little 
deformity,  but  when  it  is  oblique  there  will  be  the 
sharp  projection  of  the  upper  fragment  beneath  the 
skin,  with  mobility,  crepitus,  pain,  and  loss  of  power 
in  the  leg. 

In  fracture  of  the  tibia  alone,  which  is  often  the 
result  of  direct  violence,  the  line  of  fracture  is  fre- 
quently transverse,  and  under  these  circumstances  the 
symptoms  may  not  be  very  obvious,  for  the  fibula, 
remaining  unbroken,  acts  as  a  splint,  and  tends  to  pre- 
vent much  displacement  from  taking  place ;  in  most 
cases,  however,  crepitus  can  be  detected  on  manipu- 
lating the  limb,  and  upon  running  the  finger  along 
the  subcutaneous  edge  of  the  tibia  some  slight  iiTegu- 
larity  can  usually  be  detected  at  the  seat  of  fi-acture. 


86  Manual  of  Surgery. 

Fracture  of  the  internal  malleolus  is  a  common 
complication  of  Pott's  fracture  of  the  fibula. 

Separation  of  the  upper  and  lower  epiphyses  of  the 
tibia  are  described  as  rare  injuries. 

Fracture  of  the  fibula  alone  is  often  met  with  as 
the  result  of  indirect  violence,  the  bone  usually  giving 
way  through  its  lower  third  ;  less  frequently  it  is  due 
to  direct  violence,  the  fracture  then  taking  place  at 
the  spot  where  the  force  acts. 

The  symptoms  of  this  injury  are  often  obscure,  for 
there  is  usually  very  little  displacement  of  the  frag- 
ments, and  the  patient  can  occasionally  walk  without 
much  pain  or  difficulty.  Crepitus  and  mobility  can, 
however,  usually  be  detected,  if  pressure  is  made 
alternately  on  either  side  of  the  suspected  seat  of 
fracture,  or  if  the  foot  is  rotated  with  one  hand,  while 
the  fingers  of  the  other  are  placed  over  the  point 
where  the  bone  is  broken. 

Pott's  fi'acture  is  the  term  applied  to  a  fracture 
of  the  lower  end  of  the  fibula,  associated  with  a  disloca- 
tion outwards  of  the  foot  at  the  ankle  joint.  In  this 
injury,  which  is  usually  the  result  of  a  sudden  slip  or 
twist  of  the  foot  outwards,  the  bone  is  broken  from 
two  to  four  inches  above  its  lower  extremity,  the  ends 
of  the  fragments  being  driven  inwards  ;  the  articular 
surface  of  the  astragalus  is  displaced  from  the  tibia, 
the  foot  being  dislocated  outwards  at  the  ankle  joint ; 
in  some  cases  the  inner  malleolus  of  the  tibia  is  also 
fractured,  in  others  the  internal  lateral  ligament  is 
ruptured. 

The  signs  of  this  injury  are  usually  obvious  ;  a 
well-marked  depression  can  be  felt  at  the  seat  of  the 
fracture  of  the  fibula  ;  the  foot  is  twisted  outwards, 
and  its  sole  is  everted  by  the  peronei,  owing  to  the 
fact  that  the  fibula  no  longer  offers  any  resistance  to 
their  contraction  ;  the  inner  malleolus,  if  unbroken, 
projects  prominently  beneath   the  skin  ;  if  separated 


Dupuytren's  Fracture. 


87 


the  detached  fragment  can  be  readily  felt,  with  a 
depression  above  it,  and  crepitus  is  easily  obtained ; 
the  heel  is  drawn  up  by  the  muscles  of  the  calf 
(Fig.  15). 

Dtiptiytreii's  fi'acture  of  the  fibula  is  a  rare 
inj  ury,  in  which  there  is  not  only  fracture  of  its  lower 
extremity,  but  also  laceration  of 
the  strong  inferior  tibiofibular 
ligaments  (which  remain  intact 
in  Pott's  fracture)  ;  in  some 
cases,  a  slip  of  the  tibia  is  torn 
off  with  the  ligaments,  remain- 
ing connected  with  the  lower 
fragment  of  the  fibula.  In 
addition,  the  foot  is  displaced 
upwards  and  outwaids,  and  the 
tibia  is  sometimes  forced  through 
the  skin  on  the  inner  side  of 
the  ankle,  so  that  the  fracture 
is  rendered  compound. 

Treatment. — Most  cases 
of  fracture  of  the  tibia  and 
fibula,  or  of  either  bone  alone, 
may  be  treated  on  a  straight 
back  splint,  with  a  foot  piece  for 
the  sole  at  right  angles  to  it, 
and  two  side  splints  ;  in  the 
application  of  these,  there  are 
certain    rules    which  should    be   Fig.  1.5.— Potfs  Fracture. 

obsprvpd  viV  •  1  Tbp  im'Tifcj  (From  Pick's  "  Frac- 
ouservea,     viz.  .       1.    ±ne     joints         tures and  Dislocations.") 

above    and    below    the    seat    of 

fracture,  i.e.  the  knee  and  ankle,  should  be  fixed 
by  the  splints.  2.  The  inner  border  of  the  patella, 
the  internal  malleolus,  and  the  inner  side  of  the 
great  toe  should  be  in  the  same  line.  3.  There 
should  not  be  any  irregularity  in  the  crest  of  the  tibia. 
4.  The  foot  should  be  kept  at  right  angles  with  the 


88  Manual  of  Surgery. 

leg.  5.  The  heel  should  neither  be  allowed  to  drop 
nor  raised  too  high,  and  its  under  surface  should  be 
well  in  contact  with  the  foot  piece.  6.  Pressure 
should  be  taken  off  the  back  of  the  heel  by  means  of 
an  opening  in  the  back  splint  beneath  it,  and  by  a  pad 
placed  between  the  limb  and  the  splint,  just  above  it. 
7.  The  seat  of  fracture  and  the  toes  should  be  left 
uncovered.  8.  No  bandages  should  be  applied  be- 
neath the  back  splint. 

The  fracture  should  be  kept  in  splints  for  three  or 
four  weeks,  and  some  form  of  stiff  bandage  afterwards 
worn  for  about  the  same  period.  When  there  is  not 
much  displacement  of  the   fragments,  and  an  absence 


Fig.  16. — Cliue's  Splint. 

of  bruising  or  swelling  of  the  soft  tissues,  the  limb 
may  at  once  be  put  up  in  some  form  of  stiff  bandage, 
e.g.  plaster  of  Paris,  or  a  Croft's  splint,  and  the  patient 
in  two  or  three  days  allowed  to  go  about  on  crutches.* 
Some  surgeons  use  Cline's  splints  (Fig.  16),  viz. 
lateral  splints  with  foot  pieces ;  if  employed,  care 
should  be  taken  that  the  foot  piece  is  at  right  angles 
with  the  side  piece,  not  at  an  obtuse  angle,  as  is 
generally  the  case,  otherwise,  tlie  foot  being  kept  fixed 
with  the  toes  pointed,  considerable  weakness  and  stiff- 
ness of  the  ankle  will  afterwards  remain,  from  the 
stretching  of  its  anterior  ligament. 

*  In  applying  a  stiff  bandage  to  the  lower  extremity,  whether 
in  cases  of  recent  fracture  or  after  removal  of  splints,  care  should 
always  be  taken  that  the  foot  is  kept  at  right  angles  with  the  leg 
while  the  bandage  is  setting. 


Pott's  Fracture.  89 

Macintyre's  splint  (Fig.  14)  is  often  employed,  and 
by  means  of  the  screw  behind,  it  may  be  applied  witli 
the  limb  straight  or  bent  at  the  knee. 

The  "fracture  box,"  or  "box  splint,"  is  useful 
when  the  soft  tissues  are  much  bruised  and  swollen, 
and  also  in  some  cases  of  compound  fracture  ;  it  con- 
sists of  a  board  with  a  foot  piece  and  movable  sides, 
forming  a  kind  of  box  in  which  the  limb  is  supported 
on  a  pillow. 

If  the  limb,  after  being  put  up  in  splints,  is  sus- 
pended in  a  swing,  it  will  be  more  comfortable  for  the 
patient,  as  he  will  be  able  to  move  it  as  he  lies  in  bed 
without  disturbing  the  fracture  ;  it  may  be  swung  by 
straps  or  bandages  from  the  bed-cage,  which  should 
also  be  used  in  order  to  keep  the  weight  of  the  bed 
clothes  off  the  limb,  or  one  of  Salter's  swings  may  be 
employed.  If  the  limb  is  not  suspended,  sand-bags 
should  be  laid  on  the  bed  on  either  side  of  it  in  order 
to  steady  it. 

When  there  is  much  displacement  of  the  fragments 
and  difficulty  is  experienced  in  keeping  them  in 
position  by  any  of  the  preceding  methods,  it  will 
often  be  found  that  laying  the  limb  on  its  outer  side 
with  the  hip  and  knee  bent  will  prove  successful,  for 
in  this  posture  the  muscles  of  the  calf,  which  are  the 
chief  agents  in  producing  the  deformity,  become 
relaxed.  Occasionally  subcutaneous  division  of  the 
tendo  Achillis  may  be  required  with  the  same  object. 

In  Pott's  fracture  there  is,  in  addition  to  fi'acture 
of  the  fibula,  the  dislocation  outwards  of  the  foot, 
which  has  to  be  corrected. 

Some  surgeons  treat  this  fracture  with  a  back 
splint  and  two  side  splints  ;  but  when  put  up  in  this 
way  there  is  often  a  tendency  for  the  deformity  to 
recur. 

When  the  displacement  of  the  foot  is  well  marked, 
it  is  safer  to  use   Dupuytren's  splint,   i.e.  a  straight 


90 


Manual  of  Surgery. 


wooden  splint,  notched  at  its  lower  end,  and  reaching 
from  the  head  of  the  tibia  to  about  four  inches  below 
the  sole  of  the  foot  (Fig.  17).  This  is  applied  to  the 
inner  aspect  of  the  limb,  a  thick  pad,  not  extending 
below  the  inner  malleolus,  being  inter- 
i  /      \  posed  between  the  lov,^er  part  of  the 

splint  and  the  leg.  The  upper  end  of 
the  splint  having  been  bandaged  to 
the  limb,  the  thick  pad  is  made  to  act 
as  a  fulcrum,  across  which  the  foot 
is  drawn  to  the  lower  part  of  the 
splint ;  to  this  it  is  fastened  by  a 
figure  of  8  bandage  carried  round  the 
ankle  and  foot  and  through  the  notches 
at  its  lower  end.  This  bandage  should 
not  be  carried  round  the  ankle  higher 
than  the  external  malleolus,  otherwise 
it  would  press  the  fragments  of  the 
fibula  inwards,  and  thus  defeat  the 
object  of  this  plan  of  treatment,  which 
is  to  draw  the  foot  inwards  and  throw 
the  broken  ends  of  the  fibula  outwards.  If  the  knee 
is  bent,  and  the  limb  is  either  swung  or  laid  on  its 
outer  side,  the  muscles  of  the  calf  will  be  relaxed,  and 
in  this  way  the  tendency  for  the  heel  to  be  drawn  up 
will  be  counteracted. 

In  the  Manchester  Infirmaiy  a  modification  of 
Dupuytren's  splint  is  sometimes  employed,  and  I  have 
myself  frequently  used  it  with  very  good  results.  It 
consists  (Fig.  18)  of  an  inside  splint  with  a  foot  piece 
at  right  angles  to  it,  for  the  sole.  The  foot  is  first 
bandaged  to  the  splint,  care  being  taken  that  the 
sole  and  heel  are  well  in  contact  with  the  foot  piece. 
The  upper  part  of  the  splint  is  then  drawn  across  the 
thick  pad  (which,  being  fixed  above  the  internal 
malleolus,  acts  as  a  fulcrum),  and  bandaged  to  the  leg 
below  the  knee.     The  advantage  of  this  splint  is  that 


Fi^.  17.—  Dupuy- 
tren's Spliut. 


PO  Tt\s    Fr  ACrURE-. 


91 


^'■^■■■^^■^^' 


the  foot,  by  means  of  the  foot  piece,  is  maintained  at  a 
right  angle  with  the  leg,  instead  of  becoming  extended, 
as  is  frequently  the  case  when  the    common    Dupuy- 
tren's  splint  is  employed  ;    hence  the 
stiffness    and  weakness  of   the  ankle 
joint,    which  often    remain   after  the 
latter  is  removed,  from  stretching  of 
the   anterior  ligament,  and   from  the 
long-continued  faulty  position  of  the 
foot,  are  to  a  great  extent  prevented. 

Pott's  method  of  treating  this 
fracture  consists  in  flexins:  the  knee 
to  a  right  angle  and  laying  the  limb 
on  its  outer  side ;  for  this  purpose  an 
outside  splint  with  a  lateral  foot  piece 
may  be  employed,  the  pad  of  the  latter 
being  thicker  than  that  of  the  leg 
piece,  so  as  to  press  the  foot  inwards  ; 
to  the  inner  side  of  the  limb  a 
straight  splint  is  applied,  reaching  not 
lower  than  the  ankle,  the  two  splints 
being  bandaged  or  strapped  together. 

In  cases  of  Pott's  fracture,  where  the  displacement 
of  the  foot  has  not  been  completely  corrected,  con- 
siderable improvement  will  often  follow  the  perfor- 
mance of  osteotomy,  i.e.  subcutaneous  division  of  the 
fibula  and  forcible  strais^htening  of  the  foot,  the  case 
being  then  treated  as  one  of  recent  fracture. 

When  both  tibia  and  fibula  are  broken,  union,  as  a 
rule,  takes  place  in  from  six  to  eight  weeks,  some 
form  of  apparatus  being  usually  required  for  from  eight 
to  ten  weeks ;  in  the  case  of  fracture  of  a  single  bone, 
six  or  seven  weeks  will  generally  be  sufficient. 

The  Foot. 

Fractures  of  the  bones  of  the  foot  are  of  rare  oc- 
currence, except  as  the  result  of  severe  crushes ;  under 


Fig.  18.— Splint  for 
Pott's  Fracture. 


92  Manual  of  Surgery. 

tliese  circumstances  several  are  usually  involved,  and 
the  fracture  is  often  compound. 

Simple  fracture  of  the  os  calcis  is  sometimes  met 
with  as  the  result  of  falls  on  to  the  heel ;  if  broken 
transversely  behind  the  attachments  of  the  strong 
interosseous  ligament,  the  detached  fragment  may  be 
drawn  up  by  the  contraction  of  the  muscles  of  the 
naif.  In  many  cases,  however,  no  displacement  occurs, 
the  strong  ligaments  maintaining  the  fragments  in 
apposition,  the  only  symptoms  then  present  being 
pain  and  swelling  about  the  heel,  with  crepitus  on 
grasping  the  posterior  part  of  the  os  calcis,  and  moving 
it  from  side  to  side.  When  the  fracture  is  commi- 
nuted, the  mobility  of  the  fragments  and  the  ready 
detection  of  crepitus  will  at  once  point  to  the  nature 
of  the  injury.  In  some  cases,  as  the  result  of  sudden 
and  forcible  contraction  of  the  muscles  of  the  calf,  the 
epiphysis,  or  even  the  posterior  part  of  the  os  calcis, 
may  become  separated  and  drawn  away.  Simple  frac- 
ture of  the  astragalus,  as  the  result  of  indirect 
violence,  is  rarely  met  with,  as  are  also  fractures  of  the 
other  tarsal  bones.  Fractures  of  the  metatarsal 
bones  and  phalanges  are  always  the  result  of  direct 
violence,  and  resemble  in  theii-  general  symptoms  the 
fractures  of  the  corresponding  bones  of  the  hand. 

Treatment. — When  the  posterior  portion,  or  the 
epiphysis,  of  the  os  calcis  is  separated  and  drawn  away 
by  the  muscles  of  the  calf,  an  attempt  should  be  made 
to  relax  the  latter  and  bring  the  fragments  into 
apposition,  by  placing  the  limb  on  an  outside  splint, 
with  the  knee  flexed  and  the  foot  extended. 

In  fracture  of  any  of  the  other  bones,  the  foot 
should  be  kept  at  rest,  either  on  a  back  splint  with  a 
foot  piece,  or  by  means  of  some  form  of  stift'  bandage. 


93 


ir.     DISEASES    OF   THE    BONES. 

James  Greio  Smith, 

Inflammation. 

Bone  being  a  complex  structure,  made  up  of  elements 
of  very  ditterent  character,  shows,  when  inflamed,  a 
corresponding  variety  in  pathological  result.  Firstly, 
we  have  the  periosteum,  composed  of  an  outer  layer 
of  fibrous  tissue,  and  an  inner  layer  of  small 
active  cells.  Secondly,  we  have  the  bone  proper, 
with  its  abundant  and  comparatively  inert  matrix, 
impregnated  with  earthy  salts,  and  its  scanty  supply 
of  vessels  and  sparsely  distributed  cell  elements. 
Thirdly,  we  have  the  maiTOW,  a  highly  organised,  ex- 
ceedingly vascular  tissue,  with  very  numerous  cells 
and  little  or  no  matrix.  As  one  or  other  of  thes<> 
tissues  is  involved  we  get  tliree  leading  varieties  of 
inflammation :  periostitis,  or  inflammation  of  the 
periosteum ;  osteitis,  or  inflammation  of  the  bone 
proper ;  and  endosteitis,  or  inflammation  of  the  bony 
marrow. 

As,  however,  in  every  variety  of  inflammation  of 
bone  the  process  owes  its  existence  and  con- 
tinuation mainly  to  the  medullary  tissue,  whether  it 
is  massed  together  in  the  central  canal,  or  carried 
along  the  vessels  in  the  Haversian  systems,  or  con- 
tinued outwards  under  the  periosteum,  it  will  be 
readily  understood  that  the  varieties  run  into  each 
other.  Thus,  periostitis  usually  accompanies  osteitis, 
osteitis  soon  follows  endosteitis,  and  so  on.  In  the 
earlier  stages  the  forms  of  inflammation  are  sufl&ciently 
capable  of  distinction,  clinical  as  well  as  pathological 
In  their  later  stages  the  gross  results  may  become  so 


94 


Manual  of  Surgery. 


Pip.  19— Femur,  showing 
effects  of  supinirative  and 
of  osteo-plastic  periostitis. 
Theshaft.in  its  upper  two- 
thirds,  is  covered  with  a 
rough  deposit  of  new  peri- 
osteal 1)one  ;  in  the  lower 
third,  where  suppuration 
had  taken  place,  there  is  a 
piece  of  necrosed  lione, 
overhanpinK  which  are 
several  irregular  pointed 
masses  de\  eloped  in  the 
Btripjied  periosteum  which 
had  formed  the  ahscess 
wall.  (Museum,  Bristol 
Royal  Inflrmary.) 


involved  as  to  constitute  in  their 
totality  diseases  requiring  separate 
description  ;  siicli  are  caries  and 
nca'osis. 

Periostitis.  —  By  periostitis 
is  meant  an  inflammation  com- 
mencing in,  and  chiefly  confined 
to  the  periosteum.  It  is  met  with 
in  two  leading  forms  : 

1.  Sim2^le  local  jjeriostitiSj 
acute  or  chronic. 

2.  Diffuse  infective  2)7'eiostitis, 
always  acute. 

Simple  local  periostitis. — 
By  this  is  meant  a  simple  inflam- 
mation of  an  area  of  periosteum, 
rarely  dangerous  to  life,  and  tend- 
ing to  recovery  by  resolution  or 
after  development  of  new  bone 
or  the  formation  of  abscess. 

Causation. — The  simple  form 
of  periostitis  nearly  always  arises 
either  from  local  injury  or  from 
extension  of  inflammation  from 
the  underlying  bone  or  overlying 
soft  parts.  The  injury  may  be 
from  a  sudden  blow,  such  as  a 
kick  on  the  shin,  or  from  prolonged 
irritation,  such  as  the  pulsations  of 
an  aneurism.  Chronic  osteitis  is 
always  accompanied  by  periostitis, 
and  an  ulcer  on  the  skin  that  is 
not  distant  from  periosteum,  as  on 
the  shin  or  scalp,  will  cause  some 
degree  of  periosteal  inflammation. 

Pathology. — TJie  appearances 
of    periostitis    are    simply     those 


Periostitis.  95 

of  inflammation  of  t-he  two  tissues  which  enter  into 
its  composition.  Inflammation  of  the  outer  fibrous 
layer  causes  it  to  swell  and  become  red  or  livid. 
It  loses  its  purely  fibrous  character,  and  becomes 
pulpy  and  oedematous  ;  it  strips  more  readily  from 
the  underlying  bone,  and  appears  to  be  more  inti- 
mately connected  with  the  superimposed  muscle. 
The  layers  of  cells  next  the  bone  undergo  proliferation, 
and  these,  with  the  inflammatory  exudates,  help  to 
loosen  the  periosteal  fibre  from  the  bone.  An  exces- 
sive amount  of  proliferation  in  the  "  cambium " 
layer  may  elevate  the  fibrous  layer  some  distance  from 
the  bone,  stretching,  or  even  tearing  the  vessels  that 
pass  between  them,  and  so  causing  partial  necrosis  of 
the  outer  lamellae. 

The  process  may  eventuate  in  several  ways,  which 
have  been  described  as  varieties,  but  are  perhaps 
better  described  as  simple  terminations. 

1.  Resolution.  —  The  inflammation  may  simply 
pass  off  in  its  early  stages,  no  effects  being  per- 
ceptible beyond,  perhaps,  a  slight  production  of  new 
bone. 

2.  Periosteal  abscess.  —  As  a  result  of  simple 
local  inflammation  an  abscess,  acute  or  chronic,  may 
form  between  the  fibre  and  the  bone.  This  means 
that  the  vascular  supply  to  the  underlying  bone  has 
been  cut  off,  and  death  (necrosis)  of  the  outer  layer 
of  bone  so  nourished  follows.  An  acute  abscess  is 
usually  simply  traumatic,  and  contains  ordinary 
liquid  pus.  A  chronic  abscess  has  usually  some  pre- 
disposing influence,  such  as  scrofula,  when  its  contents 
are  of  the  well-known  cheesy  nature,  or  syphilis, 
when  the  matter  is  greenish-yellow  and  thick. 

3.  Osteo-plastic  per-iostitis. — The  development  of 
new  bone  is  one  of  the  most  characteristic  results 
of  periostitis,  and  nearly  always  follows  its  existence 
in    the    chronic    or    subacute    form.       It    is  simply 


96 


Manual  of  Surgery. 


an    increase    of    the    normal    function    following     a 
morbid  increase  of  liistological  activity.    Alow  degree 

of  inflammation  is  necessary  to 
the  production  of  new  bone  by 
periosteum.      It   is  found  esj^e- 
I'^^'if^  cially  underlying  ulcers,  in  the 

S^MlM  neighbourhood  of  deep  inflam- 

mations of  the  bone,  around  a 
foreign  body,  and  under  many 
other  similar  conditions.  If 
found  accompanying  an  acute 
inflammation,  it  is  never  in  the 
centre  of  it,  but  in  the  more  out- 
lying areas,  that  the  new  bone  is 
produced.  These  periosteal  bony 
new  growths  are  known  patho- 
logically as  osteophytes,  or  more 
correctly  as  'periosteophytes,  and 
clinically  as  periosteal  nodes 
(Figs.  19,  20,  and  21). 

ISyiiiptoiiis.  —  Pain  of  a 
bursting  or  throbbing  character 
is  the  most  prominent  symptom 
of  acute  simple  periostitis.  The 
pain  is  increased  by  pressure 
over  the  part,  and  especially  by 
tapping,  and  is  nearly  always 
woret  at  night.  There  is  some 
defined  swelling  in  the  over- 
lying soft  parts ;  the  skin  is 
either  normal  in  colour  or 
slightly  dusky. 

If  acute  abscess  forms,  the 
pain  is  intensified,  and  may  be 


Fig.  20.— Tibia  and  Fl!)ula,show- 
in?  the  effects  of  osteo-i'las- 
tic  periostitis.  Tlie  inter- 
ot'seous  luemljrane  is  aliiiofit 
completely  ossified,  and  the 
Ehafts  of  hoth  bones  are 
covered  with  rough  perios- 
teal new  growth  which  is 
carried  outwards  on  to  tlie 
flhrous  septa  between  the 
muscles.  (Museum,  Bristol 
Royal  Inflriuar.v.) 


agonising ;  the  swelling  in- 
creases, and  the  skin  becomes 
red.     In  chronic  abscess  there 


Periostitis. 


97 


is  less  pain,  but  the  swelling  will  be  more  marked  with 
vague  fluctuation  or  Vjogginess.  The  skin  in  the  early 
stages  may  be  of  normal  colour,  but  later  on  it  be- 
comes mottled,  dusky,  or  red,  ultimately  showing  the 
ordinary  signs  of  perforation  by  abscess.  In  osteo- 
plastic periostitis,  which  is  nearly  always  subacute 
or  chronic,  the  swelling  is  hard  and  unyielding,  and 
the  pain  may  be  slight  and  remittent.  Pain  is  least 
marked  in  strumous  periostitis  ;  in  syphilitic  periostitis 
it  is  always  most  severe  at  night ;  in  rheumatic 
periostitis  the  pain  is  shifting  and  uncertain  as  to 
locality  and  duration. 

Predisposing  causes,  local  as  from  injury  or  irrita- 
tion, or  constitutional  as  from  syphilis,  struma,  or 
rheumatism,  will  be  looked  for  to  help  in  the  diagnosis. 

Treatiiioiit. — In  simple  acute  periostitis  the 
patient  must  be  put  to  bed, 
the  jjart  elevated  as  much  as 
possible,  and  cold  apjjlied 
either  by  ice  or  evajDorating 
lotions.  Hot  fomentations 
or  lead  and  opiate  lotions 
may  1>e  used  instead.  If  the 
pain  is  very  severe  a  full  dose 
of  opium,  and  a  liberal  appli- 
cation of  leeches  to  the  part, 
will  probably  give  much  re- 
lief Should  the  pain  still 
continue,  and  the  febrile  dis- 
turbance remain  unabated 
after  twenty-four  hours  or  so, 
the  danger  of  suppuration 
must    be  avoided   by   a    free 

incision  through  the  periosteum  down  to  the  bone, 
either  subcutaneously  by  a  tenotomy  knife,  or  through 
the  soft  tissues  by  a  scalpel. 

When   acute   abscess  has  formed,  immediate  and 
H— 21 


Fig.  21. — Section  through  the 
Shaft  of  a  Femiu',  enor- 
mously tliickened  from 
osteo-plastic  periostitis. 
(Museum,  Bristol  Eoyal 
lufiiTuarj'.) 


9^  Manual  of  SuRGERy. 

free  incision  is  necessary.  In  chronic  abscess  con- 
nected with  syphilis,  opening  may  be  delayed  until  a 
fair  trial  has  been  given  to  specific  treatment.  In 
strumous  '  periosteal  abscess  it  will  be  well,  after 
opening,  to  scrape  the  denuded  surface  with  a  suitable 
instrument,  as  the  underlying  bone  will  probably  be 
found  carious. 

In  chronic  non-suppurative  periostitis,  where  there 
is,  in  all  probability,  some  development  of  new  bone, 
repeated  blistering  is  likely  to  be  most  successful, 
though  the  application  of  the  oleate  of  mercury  has  had 
good  results.  Iodide  of  potassium  is  supposed  to  be 
beneficial  in  promoting  bony  absorption.  Subcutaneous 
section  in  various  directions,  or  the  use  of  the  gouge, 
especially  if  there  is  much  pain,  may  occasionally  be 
recommended. 

Diffuse  infective  periostitis,  acute  ne- 
crosis, acute  diffuse  periostitis. — This  is  a  grave 
constitutional  disease,  locally  manifested  by  septic  sup- 
purative inflammation  of  the  periosteum,  resulting 
in  more  or  less  extensive  death  of  bone,  and  frequently 
attended  with  all  the  signs  of  acute  septicaemia. 

Causation. — The  affection  nearly  always  occurs 
before  puberty,  and  in  boys  more  frequently  than  in 
girls.  Various  local  causes  have  been  assigned,  such 
as  injury  and  exposure  to  cold  and  damp  ;  but  the 
ultimate  cause  is  probably  constitutional.  It  some- 
times appears  after  the  continued  fevers,  and  frequently 
in  connection  with  the  strumous  diathesis ;  but  in  a 
considerable  number  of  instances  it  is  met  with  in 
individuals  who  have  shown  no  previous  signs  of 
disease. 

Pathology. — The  pathology  of  this  disease  is 
.still  obscure.  Some  surgeons  maintain  that  acute 
necrosis  is  always  a  result  of  osteo-myelitis  ;  others 
that  it  is  a  pure  periostitis.  It  is  certainly  an  in- 
fiamniation    of    medullary    tissue,   and    this    may    be 


Per  10  s  ti  tis.  9  9 

localised  under  the  periosteum  as  well  as  in  the  central 
canal.  Practically  such  a  distinction  holds  good ; 
for  we  meet  with  a  superficial  acute  necrosis  of  part 
of  the  outer  shell,  such  as  would  be  caused  by  a 
periostitis,  as  well  as  with  a  necrosis  of  tlie  whole 
shaft,  such  as  would  be  caused  by  an  osteo-myelitis. 

The  distinguishing  marks  of  this  form  of  periostitis 
are  the  rapidity  and  certainty  with  which  suppuration 
supervenes,  and  the  uniformity  with  which  micro- 
organisms are  found  in  the  pus.  The  purulent  fluid 
forces  its  way  between  the  periosteum  and  the  bone, 
completely  severing  the  connection  between  the  two, 
tearing  through  the  nutrient  vessels,  and  leaving  the 
surface  of  the  bone  to  die.  The  condition  may  be  de- 
scribed as  a  septic  abscess  confined  under  gi'eat  pressure 
between  periosteum  and  bone.  The  results  of  such  a 
condition  in  death  of  bone  and  septic  infection  of  the 
system  are  readily  understood. 

Symptoms. — The  symptoms  are  nearly  always 
urgent.  A  sudden  access  of  high  fever,  often  ushered 
in  with  a  rigor  ;  profound  constitutional  disturbance, 
local  deep-seated  pain,  with  swelling  or  signs  of 
suppuration  in  the  soft  parts  overlying  a  bone,  point 
to  acute  diffuse  periostitis.  At  the  outset  local  signs 
may  be  slight  or  absent ;  but,  as  the  disease  progresses, 
they  become  more  urgent.  Delirium  is  frequently 
present  from  an  early  stage. 

The  site  is  usually  in  one  of  the  long  bones,  and 
especially  in  the  tibia,  femur,  or  humerus.  The  signs 
of  inflammation,  obscure  at  the  beginning,  in  a  ^-ery 
short  time  become  marked  with  redness,  puthness, 
and  oedema  of  the  skin,  quickly  to  be  followed  by 
evidence  of  suppuration.  At  this  stage  symptoms  of 
septicaemia,  often  of  the  most  aggravated  form,  may 
supervene  ;  and  the  patient  may  die  in  a  few  days,  or 
linger  for  weeks  with  abscesses  in  the  joints  or  in 
other  parts  of  the  body.      Not  unfrequently,  however, 


loo  Manual  of  Surgery. 

and  especially  if  the  disease  has  been  recognised  and 
properly  treated  from  the  beginning,  a  favourable 
result  ensues. 

Treatment. — The  only  treatment  likely  to  be  of 
benefit  is  early  and  free  incision  of  the  periosteum, 
wherever  pain  or  swelling  may  localise  the  afiection. 
As  a  tendency  to  septicaemia  already  exists,  the  strict 
observance  of  the  practice  of  antiseptics  will  be 
advisable.  If  done  early  enough,  such  incision  is 
usually  followed  by  a  marked  improvement  in  all  the 
symptoms.  Early  incision  not  only  minimises  the 
risks  of  blood  poisoning,  but  saves  the  bone  from 
extensive  denudation  aud  consequent  necrosis. 

Supporting  or  even  strongly  stimulating  consti- 
tutional treatment  will  be  called  for  in  all  cases.  No 
special  drug  is  likely  to  be  of  benefit.  The  question 
of  amputation,  though  it  may  arise,  is  not  so  likely  to 
be  pressing  as  in  the  allied  disease  of  acute  osteo- 
myelitis. 

Osteitis. — By  osteitis  is  meant  an  inflammation 
in  the  substance  of  true  bone,  varying  in  intensity 
and  duration,  and  ending  in  resolution,  or  in  thickening 
of  its  tissue,  or  in  various  forms  of  degeneration. 

Causation.  —  The  simple  forms  of  osteitis  are 
usually  caused  by  injury.  Frequently  a  diathesis 
or  cachexia,  such  as  scrofida,  syphilis,  or  rheumatism 
co-exists  with  special  forms  of  osteitis,  and  is  credited 
with  being  either  the  active  or  the  predisposing  cause. 
Exposure  to  climatic  influences  (cold,  damp,  malaria) 
has  been  known  to  produce  the  disease. 

Patholoyij.  —  The  effects  of  inflammalit>n  in 
Vjone  are  produced  almost  entirely  through  its 
medullary  tissue.  The  bone  cells  proper  take  little, 
if  any,  pai't.  Each  Haversian  syistem,  with  its  artery, 
vein,  nerve,  lymphatics  and  delicate  cellular  tissue  in 
the  central  canal,  and  its  concentric  lamellae,  arranged 
like  the  leaves  of  a  roll   of  music   around  this  canal, 


Osteitis.  loi 

may  be  regarded  as  an  ossicle  or  long  bone  in 
mii)iatiu-e,  rei)eating  in  itself  in  detail  what  occurs  in 
bulk  in  the  whole  bone.  The  first  steps  are  vascular 
engorgement,  inflammatory  exudation,  and  cellular 
hyperplasia  in  the  soft  tissues  lying  in  the  canal. 
This  increased  activity  is  associated  with  a  rapid 
solution  and  removal  of  the  bone  substance.  AY  here 
the  bone  is  not  compact,  but  areolar,  the  same  thing 
goes  on,  but  with  more  rapidity  and  vigour  on  account 
of  the  greater  proportionate  amount  of  the  soft  tissue. 
Bony  rarefaction  and  cellular  hyperplasia,  always  the 
initial  result,  may  go  on  indefinitely  to  reach  the 
dignity  of  a  special  variety  of  osteitis  ;  rarefying 
osteitis  or  caries.  Should  the  inflammation  be  very 
acute,  the  rapid  cellular  overgrowth  causes  strangu- 
lation of  the  confined  vessels,  and  the  bone  which 
depends  on  them  for  vitality  dies  ;  necrosis.  In  the 
more  chronic  forms  of  inflammation  the  bone  which 
is  absorbed  is  replaced  by  new  bone,  often  in  excessive 
amount,  causing  ingrowths  or  outgrowths,  with 
general  increase  in  density  ;  osteo-plastic  osteitis,  osteo- 
sclerosis. Occasionally,  again,  the  inflammatory  pro- 
cess results  in  a  localised  collection  of  pus  in  the 
midst  of  the  bony  tissue,  which  increases  by  absorptive 
distension  of  the  outlying  bone  ;  abscess  of  hone. 

Each  of  these  processes,  as  being  terminal  varieties 
of  more  clinical  importance  than  the  simple  initial 
inflammation,  will  receive  separate  consideration. 

Symptoms. — The  most  important  sign  of  simple 
osteitis  is  pain  of  a  deep-seated  boring  or  gnawing 
character,  which  is  liable  to  exacerbations  and  remis- 
sions. The  pain  is  usually  worst  at  night,  and  is 
always  increased  by  unrest  or  exercise.  An  ele- 
vated position  of  the  inflamed  part  relieves  the 
pain  ;  this  is  well  seen  in  inflammation  of  the  bones 
of  the  leg  or  foot,  wliere  the  pain,  aggravated  by  walk- 
in  or.  is  at  once  relieved  by  elevation.     There  may  be 


102  Manual  of  Surgery. 

slight  clnsky  redness  of  the  overlying  skin,  but  some- 
times thei'e  is  abnormal  paleness  from  oedema.  Swell- 
ing of  the  soft  tissues  is  usually  slight ;  enlargement 
of  the  bone  is  late  in  appearing,  and  is  chiefly  an  effect 
of  extension  of  inflammation  to  the  periosteum. 

It  is  always  diflicult  and  often  impossible  to  dia- 
gnose simple  osteitis  from  simple  periostitis.  In 
osteitis  the  deep  boring  character  of  the  pain,  and  its 
continuation  in  varying  intensity  over  long  periods  of 
time,  without  much  apparent  effect  on  the  soft  tissues, 
are  the  leading  guides.  In  periostitis  the  pain  is  more 
superficial,  and  steadily  increases  in  severity  without 
intermissions,  while  swelling  rarely  fails  to  manifest 
itself  at  a  compai-atively  early  stage.  Percussion  or 
tapping  with  the  finger  may  be  of  assistance  in  form- 
ing a  diagnosis.  Tapping  over  the  area  of  an  osteitis 
causes  a  deep  thrill  of  pain  to  shoot  through  the  whole 
bone,  which  may  last  for  some  time  afterwards ;  in 
periostitis  tapping  causes  a  temporary  aggravation  of 
tlie  superficial  pain  only.  Pressure  considerably 
aggravates  the  pain  in  periostitis  ;  it  may  not  affect,  or 
may  even  relieve  the  pain  in  osteitis. 

Trcatiiieiit. — The  part  must  be  put  at  rest,  and 
elevated  as  much  as  possible.  In  the  early  stages  of 
simple  acute  osteitis,  the  local  abstraction  of  blood  by 
leeching  or  cupping  will  usually  relieve  the  pain  and 
benefit  the  disease.  Lead  and  opiate  lotions,  applied 
hot,  are  soothing.  If  the  pain  is  very  severe  and  the 
fever  is  high,  drilling  the  bone  in  several  directions, 
through  a  small  incision  made  with  a  tenotomy  knife, 
Vill  nearly  always  afford  relief  and  often  effect  a  cure. 
Such  drilling  gives  rest  to  confined  and  compressed 
exudations,  relieves  engorgement  of  vessels,  and  pro- 
vides drainage.  In  chronic  cases,  rest,  with  repeated 
blistering,  or  the  application  of  counter-irritants,  is 
beneficial.  The  last  resort  in  every  case  is  removal 
of  part  of  the  surface  of  inflamed  bone,  by  trephine  or 


Osteitis. 


10 


gouge.  No  case  ouglit  to  bo  alloNvod  to  drift  into 
caries  or  necrosis  or  abscess,  witliout  a  trial  having 
been  given  to  trephining  or  gouging. 

The  constitutional  treatment  is  generally  that  of 
the  fevered  state.     Benefit  has  been  derived  from  tlie 


■iH^Himntai 


qjli  I  t'^^rnu^^ !  Li  1 1 1  ij('jiti  d[i  F  ^^v  'ii' MT-'  i-l!  f;;^^^^ 


Fig.  22. — Caries  of  the  Bones  of  tlie  Cranium.  There  is  rarefaction, 
with  destiuction  of  bony  tissue,  but  no  development  of  inflam- 
matory new  bone.    (Museum,  Bristol  Royal  Infirmary-.) 


administration  of  mercury  to  the  extent  of  ptyalism 
If  the  pain  be  very  severe,  opium  is  indicated.     Any 
diathesis,    rheumatic,    gouty,  syphilitic,  or  strumous, 
which  may  be  supposed  to  influence  or  predispose  to 
the  complaint,  is  treated  by  its  proper  remedies. 

Varieties   aii<l  teriiiiiiatioiis  of  osteitis.— 
These,   as   being  clinically  morp  important   than   the 


I04  Manual  of  Surcerv. 

simple  and  typical  form  of  inflammation  of  bone,  aro 
described  as  separate  diseases.     They  are  : 

1.  Rarefying  osteitis.  Known  also  as  inflamma- 
tory osteo-porosis,  and  most  frequently  as  caries. 

2.  Osteo-jjiastic  osteitis.  Known  also  as  sclerosis 
of  bo7ie. 

3.  Abscess  of  hone. 

4.  Necrosis,  or  death  of  the  bone.  This,  as  being 
also  a  result  of  endosteiti.s,  will  be  described  after 
that  disease. 

Caries ;  rarefying  osteitis  ;  iiiflammatory 
osteo-porosis. — By  caries  we  mean  a  chronic  in- 
flammation of  bone  attended  with  absorption  or  rare- 
faction of  bony  tissue,  and  increase  of  the  cellular 
elements,  which  are  liable  to  degenerate  and  become 
purulent. 

Causation.  —  Constitutional  weakness  of  some 
sort  is  usually  the  cause  of  an  osteitis  becoming 
rarefying  or  suppurative.  Tiie  patient's  health  may 
have  been  weakened  by  want  of  proper  food,  or  bad 
hygienic  surroundings ;  most  frequently  a  specific 
disease,  particularly  scrofula  or  syphilis,  may  be 
credited  with  the  causation. 

Pathology. — The  essential  features  in  the  patho- 
logical anatomy  of  caries  are  absorption  and  replace- 
ment by  proliferating  medullary  tissue  of  the  systems 
and  trabeculse  of  bone.  The  compactness  and  density 
of  the  bony  tissue  are  diminished,  making  the  bone  ap- 
pear more  porous  when  macerated,  and  more  soft  and 
friable  when  fresh  (Fig.  22).  Pathologically  it  is 
impossible  to  distinguish  between  a  simple  rarefying 
osteitis  and  a  suppurative  disintegrating  caries ;  the 
one  is  a  more  advanced  stage  of  the  other. 

Karefying  osteitis  is  most  common  in  cancellous 
bone ;  that  is,  wherever  red  marrow  is  found.  Its 
favourite  sites  are  in  the  ends  of  the  long  bones,  in 
the  bodies  of  the  vertebrae,  and  in   the   bones  of  the 


Caries.  105 

feet  and  hands.  Bearing  in  mind  the  undoubted 
similarity  in  structure  and  functions  between  red 
marrow  and  lymph-glandular  tissue,  and  the  fact  that 
in  sci-ofula  both  tissues  frequently  undergo  changes 
that  are  almost  identical  and  often  associated,  we  can 
scarcely  avoid  the  conclusion  that  caries  is  an  effect 
of  scrofulous  lymphadenitis.  The  implication  of  bone 
is  simply  an  accident  of  lymph-glandular  tissue  being 
placed  in  its  meshes ;  the  active  cause  must  be  sought 
in  the  inflamed  marrow.  Many  other  considerations, 
not  the  least  important  of  which  is  tlie  discovery  of 
giant  cells  and  tubercular  bacilli  in  certain  cases 
of  caries,  confirm  the  belief  that  strumous  o:land 
disease  and  fungating  caries  are  in  most  respects 
identical. 

Simple  rarefying  osteitis,  owning  no  constitutional 
cause,  and  simply  induced  by  traumatism,  is  not  very 
common.  In  its  purest  form  it  is  seen  as  a  result  of 
constant  traumatic  irritation,  such  as  miglit  be  pro- 
duced by  the  pulsations  of  an  aneurism.  There  is  here 
simple  cellular  overgrowth  at  the  expense  of  the  bony 
trabeculte  ;  the  changes  peculiar  to  the  commoner 
strumous  forms  are  absent. 

The  minute  changes  in  rarefying  osteitis  are  some- 
what varied.  There  is  always  an  excess  of  cellular 
growth,  or  granulation  material  of  a  somewhat  de- 
generate type.  The  cells  everywhere  crowd  the 
trabecular  spaces,  fill  the  Haversian  canals,  and  occupy 
new  channels,  which  are  formed  in  all  directions 
through  the  compact  bone  (Fig,  23).  The  bony  tissue 
disappears  in  front  of  these  granulations  in  different 
manners.  In  most  situations  it  passively  falls  to 
pieces  in  small  granules  or  portions  of  lamellae  along 
the  natural  lines  of  cleavage.  Frequently  it  is  ab- 
sorbed in  hollows  or  lacunae  {Hoicships  lacunct),  in 
each  of  which  may  be  found  large  vigorous  looking 
cells  (osteoclasts),  and  occasionally  the  loop  of  a  small 


io6 


Manual  of  Surgery. 


blood-vessel.  Sometimes  in  the  larger  hollows  are 
found  masses  of  coherent  protoplasm,  containing 
several  nuclei,  and  known  as  giant  cells.  Special 
forms  of  giant  cells,  not  occupying  lacunse,  with  long 
processes,  and  often  containing  rod-shaped  bacilli,  are 
found   amonfj   the  granulations    in  tubercular  caries. 


Fig.  23.— Section  (x  50)  tliroiigh  the  protruding  end  of  a  Femur  on  a 
stump  after  amputation  of  the  Thigh.  On  the  right  are  seen  the 
appeai'ances  of  simple  rarefying  osteitis  in  compact  bone ;  on  the 
left  is  visible  a  considerable  development  of  periosteal  new  bone  of 
the  usual  areolar  character. 


In  every  case  the  bone  corpuscles  are  essentially 
passive,  simply  undergoing  fatty  or  granular  degene- 
ration in  the  enlarged  and  corroded  lacunne. 

These  minute  changes  may  produce  different  gross 
results.  Sometimes  the  granulations  remain  qui- 
escent, or  undergo  a  harmless  fatty  change,  and  there 
is  no  formation  of  pus  ;  dry  caries,  or  caries  sicca. 
.>ro)T'  frofjuontly  tlio  gi-anulations  invade  neighbouring 


Caries. 


107 


m\ 


tissues^  sprouting  through  the  skin  or  into  a  joint  ; 
fungating  caries,  or  caries fungosa.  In  the  more  active 
forms  an  area  perishes,  and 
this,  set  free  by  the  action  of 
tlie  living  granulations  around 
it,  is  left  as  a  piece  of  dead 
bone  in  the  centre  of  the  in- 
flamed district;  necrotic  caries 
caries  necrotica  (Fig.  24). 

Occasionally  one  or  more 
abscesses  form  in  the  heart  of 
the  fungating  granulations  to 
become  united  in  one  pus-con- 
taining cavity  to  be  presently 
described  as  abscess  of  bone. 

Generally  speaking,  the 
final  changes  in  rarefying 
osteitis  resolve  themselves 
into  one  or  other  of  three 
groups  : 

(1)  Simple  resolution  and 
return  to  health,  as  in  some 
cases  of  hip  joint  disease. 

(2)  Caseation,  fatty  de- 
generation, or  even  calcifica- 
tion of  the  inflammatory  pro- 
ducts ;  conditions  which  may 
remain  quiescent  for  years, 
but  are  rarely  permanently 
harmless. 

(3)  Most  common  of  ali 
is  breaking  up  of  the  granula- 
tions, and  the  formation  of  an 
open  sinus  through  which  the 
purulent  matter  and  liony 
detritus  are  discharged. 

The  naked-eye  appearances 


t^ 


V•^-V 


y/i 


m 


Fit,'.  24.— Femur  affected  in  its 
upper  and  lower  thirds  with  ad- 
vanced rarefying  osteitis,  in  its 
middle  third  with  central  necro- 
sis. In  the  middle  of  the  shaft  a 
small  piece  of  necrosed  bone  lies 
loose  in  a  cavity  surrounded  ]>y 
sclerosed  bone,  which  is  tra- 
versed by  a  long  channel  leading 
to  an  opening  in  the  shaft  liieher 
up.  (Museum,  Bri.«tol  Koyal 
Infirmary. J 


loS  Manual  of  Surgery. 

of  carious  bone  are  cliaracteristic  enoiigli.  The  whole 
tissue  is  softened,  so  that  it  may  be  cut  with  the  knife 
or  crushed  betw^een  the  fingers.  Semifluid,  fatty,  or 
purulent  material  exudes  from  the  surface  on  section 
or  pressure ;  and  small  collections  of  pus  or  cheesy 
material  are  often  found  throughout  the  diseased 
substance.  AVhen  macerated  the  increased  porousness 
and  fragility  of  the  true  bony  material  becomes 
very  evident ;  a  macerated  carious  bone  may  not 
weigh  one-tenth  of  that  which  it  ought  to  w^eigh  when 
healthy  (Fig.  22). 

Symptoms.  —  The  earliest  signs  of  caries  are 
simply  those  of  chronic  osteitis  ;  it  is  impossible  to 
distino^uish  the  one  from  the  other  till  evidences  of 
suppuration  appear.  When,  with  a  history  of 
osteitis,  redness,  swelling,  and  obscure  fluctuation 
come  on  in  the  soft  parts,  we  may  suspect  caries. 
The  same  history  w^ith  the  disease  localised  near  a 
joint,  and  followed  by  signs  of  inflammation  in  that 
joint,  also  indicates  caries.  Unequivocal  signs 
appear  after  the  abscess  has  burst  or  has  been 
opened,  wdien  bare  softened  bone  may  be  felt  with  a 
probe  at  the  bottom  of  the  abscess  cavity.  When  the 
first  collection  of  matter  is  discharged  the  abscess 
walls  collapse,  leaving  a  sinus  leading  down  to  the 
diseased  bone,  through  which  watery  pus  and  bony 
detritus  are  discharged.  Such  discharge,  if  of  long 
standing,  is  usually  very  foetid.  The  granulations 
lining  the  sinus  and  overlying  the  diseased  bone  are 
usually  of  an  unhealthy  flabby  nature,  and  merge 
impercejitibly  into  the  surrounding  skin,  which  is 
usually  swollen  and  of  a  dusky  red  colour,  over- 
lapping the  sinus  with  thin  irregular  margins.  Occa,- 
sionally,  and  particularly  in  caries  of  the  bones  of 
the  hands  and  feet,  the  compact  outer  shell  is  con- 
siderably expanded  and  thinned  out  by  the  fungating 
granulations  inside,  forming   one    of    the  conditions 


Caries.  109 

which  used  to  be  called  spina  ventosa.  Such  a  con- 
dition is  essentially  a  large  chronic  abscess  in  bone. 

In  caries  of  bones  lying  at  some  distance  from  the 
surface,  as  the  spine,  the  hip,  or  the  femur,  the  sinus 
may  pursue  a  long  and  tortuous  course  through  the 
soft  tissues.  In  such  cases,  also,  t\vo  or  more  sinuses 
may  be  found  leading  to  the  same  diseased  area. 

Treatment. — In  the  treatment  of  caries  attention 
to  the  constitutional  element  is  of  special  impor- 
tance. If  the  cause  is  scrofula,  cod-liver  oil  and 
the  iodide  of  iron  are  the  most  valuable  medicinal 
remedies.  Of  equal  value,  however,  are  a  varied 
and  nourishing  dietary,  plenty  of  fresh  air,  and,  if 
possible,  an  existence  chiefly  out-of-doors.  For 
syphilis  similar  hygienic  measures  with  iodide  of 
potassium  are  indicated. 

Locally  there  is  but  one  treatment  of  value  for 
carious  bone  ;  removal  of  it.  Blisters,  setons,  absorb- 
ents, and  the  like  are  all  useless ;  the  only  plan  that 
promises  success,  if  the  disease  resists  constitutional 
treatment,  is  to  remove  the  sluo^<?ish  granulations 
entangled  in  the  bony  meshes  along  with  the  bone 
that  retains  them.  Most  frequently  this  can  be  done 
without  interference  with  neighbouring  tissues;  but 
occasionally,  as  wdien  the  disease  involves  a  joint, 
the  articulation  may  have  to  be  removed  with  the 
bone,  or  even  the  whole  limb  may  have  to  be 
amputated.      [See  Diseases  of  Joints.) 

The  removal  of  carious  bone  is  best  conducted 
with  the  limb  bloodless.  The  diseased  bone  is  ex- 
liosed  by  an  incision,  linear  or  T-  shaped,  or  crucial, 
as  seems  most  convenient.  If  the  bone  is  very  soft 
a  Volkmann's  spoon  may  suffice  for  its  removal,  but 
usually  a  gouge  will  be  required  to  complete  the 
excision  of  the  diseased  portions.  An  osteotrite  or 
similar  instrument  will  sometimes  be  of  use.  Scraping 
or    gouging    is    to    be    proceeded    with    till    marked 


no  AIA^■UAL  OF  Surgery. 

increase  of  resistance  shows  that  healthy  bone  has 
been  reached.  In  removing  diseased  portions  that  lie 
at  a  considerable  distance  from  the  surface,  or  dan- 
gerously close  to  important  structures,  the  gouge 
forceps  will  be  found  a  useful  instrument.  The 
unhealthy  granulations  along  the  sinuses  are  to  be 
thoroughly  removed  by  scraping,  and  the  whole  of 
the  disease  replaced  as  far  as  possible  by  healthy  raw 
wounds. 

In  cases  of  great  distension  of  the  bony  shell,  as 
in  scrofulous  caries  of  the  long  bones  of  the  hands  or 
feet,  it  may  be  advisable  to  remo\'e  by  scissors  con- 
siderable slices  of  the  bone  and  skin,  leaving  an 
open  gutter  to  heal  from  the  bottom  by  granulations. 
In  a  few  instances  it  may  be  possible,  with  strict 
antisepticism,  to  get  primary  healing  through  tilling 
of  the  cavity  with  blood  clot ;  in  the  majority,  how- 
ever, we  must  expect  a  very  gradual  cure  by  the 
growth  of  granulations  from  the  bottom  of  the  scraped 
cavity. 

The  open  tracts  and  cavities  left  after  scraping  are 
plugged  with  lint  soaked  in  some  trustworthy  anti- 
septic, such  as  terebene  or  chloride  of  zinc  solution. 
This  prevents  bleeding,  which  is  sometimes  free,  and 
destroys  any  remaining  foetor.  The  plug  may  be 
removed  at  the  end  of  twenty-four  hours,  and  re- 
placed by  a  simple  external  absorbent  and  antiseptic 
dressing.  Perfect  drainage  supplemented  by  occasional 
syringing,  and  the  insufflation  of  iodoform,  will 
expedite  the  process  of  cure. 

Osteo  -  plastic  osteitis ;  osteo  -  sclerosis  ; 
sclerosis  or  thickening  of  bone. — By  this  is 
understood  a  form  of  chronic  osteitis,  attended  by  a 
development  of  new  osseous  tissue,  which  adds  to  the 
density,  and  sometimes  as  well  to  the  size  of  the  bono 
affected. 

Causation. — It  is  impossible  to  specify  any  distinct 


Sclerosis.  hi 

causative  influence.  In  most  cases  it  is  simply 
tlie  curative  process  of  an  ordinary  osteitis  run  to 
excess.  A  foreign  body,  such  as  a  bullet,  embedded 
in  a  bone  may  produce  effects  which  are  clinically 
apparent  only  as  sclerosis.  Syphilitic  inflammations 
of  bone  are  liable  to  result  in  thickening.  An  area  of 
sclerosis  is  found  surrounding  an  abscess  in  bones. 

Pathology. — There  is  no  special  histological  lesion 
in  sclerosis ;  the  condition  is  at  all  points  iden- 
tical with  the  condensation  and  thickening  of  bone 
which  follows  up  a  rarefying  osteitis  that  is  getting 
well.  The  result  is  a  general  increase  in  the  amount  of 
formed  bone,  with  corresponding  diminution  in  the  size 
of  the  spaces.  Sometimes  the  encroachment  on  vessels 
is  so  great  that  they  are  obliterated,  and  a  piece  of 
bone  becomes  necrosed,  and  is  cast  off  (Fig.  24). 

Symptoms. — The  symptoms  are  those  of  chronic 
osteitis,  with,  in  addition,  evidences  of  increase  in  the 
size  of  the  bone.  Pain  is  not  usually  severe,  and  is 
fugitive  and  uncertain.  Except  in  association  with 
syphilis,  we  clinically  do  not  meet  with  simple  osteo- 
sclerosis ;  it  is  nearly  always  a  sequence  of  some  other 
and  recognisable  form  of  inflammation,  traumatic  or 
suppurative.  Sclerosis  is  always  associated  with  the 
later  stages  of  necrosis,  and  may  be  the  cause  of  the 
wandering  pains  felt  in  the  thickened  and  still  inflamed 
bone.  It  exists  for  some  time  around  the  united  ends 
of  fractured  bone,  and  in  this  situation  may  be  the 
site  of  pain  lasting  over  several  years. 

T'reatment. — No  very  detinite  rules  for  treatment 
can  be  laid  down.  Comparative  rest  to  the  part, 
and  the  application  of  counter-irritants  or  blisters,  are 
most  likely  to  be  of  use.  Mercury  and  iodide  of 
potassium  are  supposed  to  be  useful  in  this  form  of 
inflammation  of  bone,  chiefly,  no  doubt,  through  their 
influence  on  syphilis,  which  is  frequently  a  factor  in 
sclerosis.       In   cases    attended    with    much    pain,   or 


ft 


112  Manual  of  Surgery. 

signs  of  considerable  inflammation,  drilling  in  various 
situations  may  be  of  benefit. 

Abscess  ill  bone, — By  this  name  is  known  a 
condition,  usually  chronic,  in  which  a  localised  col- 
lection of  purulent  matter  exists  in  the  substance  of  a 
bone. 

Causation. — The  influences  which  make  an  inflam- 
mation become  suppurative  are  probably  the  same 
for  bone  as  for  other  tissues.  Feebleness  of  consti- 
tution, and  more  especially  the  strumous  diathesis,  is 
made  to  account  for  most  cases.  In  a  few,  however, 
mere  acuteness  of  inflammation  without  any  signs  of 
general  disease  must  be  reckoned  as  causative. 
Micro-organisms  have,  in  some  instances,  been  found 
in  the  pus  evacuated ;  this  would  suggest  a  septic 
soui'ce.  A  good  many  cases  are  supposed  to  originate 
in  the  breaking  u])  of  caseated  tuberculous  masses. 

Pathology. — The  early  stages  of  abscess  in  bone 
are  simply  those  of  rarefying  osteitis.  When  the 
cancellated  tissue  is  completely  absorbed,  the  cellular 
growth  which  is  left  simply  degenerates  into  an  abscess. 
The  periphery  of  the  abscess  cavity  is  occupied  by 
gi'anulations  which  contribute  to  its  enlargement  by 
absorption  of  the  surrounding  bone  and  secretion  of 
pus.  In  the  more  outlying  areas,  away  from  the  focus 
of  inflammation,  there  goes  on  an  osteo-plastic  osteitis,, 
or  thickening  of  bone,  which  tends  to  limit  the  extension 
of  the  abscess  and  to  make  its  progress  extremely 
chronic.  In  spite  of  this  limiting  sclerosis,  however, 
the  size  of  the  abscess  slowly  increases,  till  it  may 
attain  to  a  diauiet^r  several  times  greater  than  tliat  of 
the  Vjone  in  which  it  is  situated.  In  the  centre  of  the 
abscess  cavity  a  piece  of  necrosed  bone  may  be  found ; 
but  usually  its  contents  are  simple  pus,  curdy  and 
unhealthy. 

Symptoms. — In  the  early  stages  the  signs  of 
abscess    in    bone    are    those    of    <leep-seated    chronic 


Abscess  of  Bone.  i  r  3 

inflammation.  The  most  prominent  feature  is  pain  of 
a  se\'ere  boring  or  lancinating  character,  worst  at 
night,  and  liable  to  exacerbations  and  remissions. 
There  is  usually  tenderness,  localised  in  one  spot ; 
and  sharp  taps  on  this  spot  considerably  aggi-avate  the 
pain.  The  pain  may  disappear  for  days  or  even  weeks, 
iDut  it  always  recurs,  either  spontaneously  or  after 
slight  provocation. 

At  first  there  is  no  visible  alteration  in  the  over- 
lying skin,  but  later  a  diffuse  dusky  redness,  with 
some  swelling,  makes  its  appearance.  When  the  ab- 
scess attains  to  considerable  dimensions,  the  swelling 
and  redness  may  be  marked  features  ;  but  relief  is 
nearly  always  sought  for  and  obtained  before  this. 
Some  rise  of  temperature  and  other  signs  of  abscess 
confined  under  tension  will  probably  be  found. 

In  the  majority  of  instances  the  disease  is  found  in 
the  head  of  the  tibia.  The  amount  of  matter  present 
is  usually  very  small,  seldom  more  than  a  drachm, 
and  very  rarely  so  much  as  an  ounce. 

Treatment. — The  treatment  of  abscess  in  bone 
is  simply  that  of  abscess  elsewhere,  evacuation.  The 
limb  is  made  bloodless  by  elevation,  or  by  Esm arch's 
bandage,  and  the  bone  exposed  by  a  suitable  incision. 
The  periosteum  may  or  may  not  be  elevated ;  on  the 
whole  it  is  perhaps  best  to  remove  it,  as  rajnd  growth 
of  new  bone  over  the  abscess  cavity  is  not  desirable. 
The  bone  will  probably  be  thickened  and  indurated, 
so  that  perforation  will  be  somewhat  difficult.  Vari- 
ous methods  of  piercing  the  bone  are  in  use.  Tre- 
phining, gouging,  perforation  by  bone  drill,  and  linear 
osteotomy  by  Hey's  saw,  have  all  been  recom- 
mended and  successfully  used.  As  good  a  plan  as 
any  would  probably  be  by  the  combined  use  of  the 
drill  and  the  gouge,  the  drill  being  used  to  discover 
the  situation  of  the  abscess,  and  the  gouge  to  enlarge 
the  opening.  A  large  drill  is  attached  to  an  engine, 
1—21 


IT4  Manual  of  Surgery. 

such  as  dentists  use,  and  is  pushed  through  the  bone 
in  the  direction  in  which  the  abscess  is  supposed  to 
lie.  If  pus  does  not  How  through  the  hole  first 
pierced,  the  drill  may  be  pushed  in  several  other 
directions  till  matter  is  met  with.  A  probe  is  now 
placed  in  the  hole  made  by  the  drill,  and  the  gouge  or 
trephine,  guided  by  the  probe,  is  made  to  remove  a 
piece  of  bone  sufficiently  large  to  permit  of  the  cavity 
being  scraped,  and  to  provide  free  drainage.  Good 
results  have  been  got  from  the  use  of  Hey's  saw  alone  ,' 
a  longitudinal  section  of  the  bone,  by  saw,  is  very 
likely  to  enter  the  cavity,  but  most  surgeons  would 
prefer  to  enlarge  the  opening  so  made.  The  objection 
to  the  trephine  alone  is,  that  after  a  tedious  operation, 
and  the  removal  of  a  large  piece  of  bone,  the  abscess 
cavity  may  not  be  reached.  The  preliminary  use  of 
the  rapidly  working  bone  drill  obviates  this  risk. 

The  cavity  thus  freely  exposed  is  cleared  of  its 
contents,  and  scraped  or  mopped  out  with  some  powerful 
antiseptic.  Syringing  with  antiseptic  lotions,  in- 
sufflation of  iodoform,  and  provision  for  free  drainage 
would  probably  represent  the  best  subsequent  treat- 
ment. If  the  abscess  is  not  putrid,  the  complete 
antiseptic  method  will  give  the  best  results.  The 
process  of  cure  must  in  any  case  be  slow,  as  the 
dense  bone  surrounding  the  cavity  gives  only  scanty 
blood  supply  to  the  granulations  by  which  the  cavity 
must  be  filled,  and  through  which  the  new  bone  must 
be  developed. 

r^ndosteitis;  osteo-myelitis ;  niedullitis; 
iiiflammatioii  of  the  marrow  or  medtilla  of 
1>oiie. — Inflammation  of  the  bony  marrow  occurs  in 
two  leading  forms  :  (1)  Simple  osteo-myelitis,  acute 
or  chronic  ;  (2)  Diffuse  septic  osteo-myelitis,  always 
acute. 

Simple  osteo-myelitis  is  not  of  much  clinical 
importance.      In   its  acute  form  it  is  always  the  result 


OSTEO-Mi  'ELITIS.  115 

of  injury,  and  more  particularly  of  fracture.  Some 
degree  of  osteo-myelitis  is  essential  to  the  healing 
process  in  fracture  ;  in  compound  fractures  the  in- 
flammation may  be  suppurative,  and  may  extend  some 
distance  up  the  bony  canal. 

In  its  chronic  form  osteo-myelitis  specially  lays 
liold  of  the  pink  marrow  at  the  ends  of  the  long 
bones.  The  important  part  which  the  marrow  plays 
in  all  forms  of  bony  intlaramation  has  already  been 
pointed  out,  and  need  not  further  be  dwelt  upon. 
All  such  inflammations  in  the  marrow  at  the  ends  of 
the  long  bones  are  intimately  connected  with  one  form 
of  so-called  scrofulous  joint  disease. 

DiHiise  septic  osteo-myelitis ;  acute  diffuse 
osteo-myelitis  ;  acute  necrosis. — These  names 
have  been  given  to  an  acute  septic  inflammation 
diflused  through  the  marrow  of  long  bones,  and 
usually  terminating  in  death  of  the  shaft. 

It  is  closely  related  to  and  probably  pathologically 
identical  with  the  disease  already  described  as  acute 
suppurative  periostitis,  with  the  synonym  also  of 
acute  necrosis.  The  clinical  features  difler  according 
to  the  situation  of  the  marrow  aflected,  periosteal  or 
endosteal.  A  third  variety  of  septic  osteo-myelitis, 
described  by  German  writers  as  idiopathic  and  in- 
fective, is  probably  identical  with  the  disease  now  to 
be  described,  and  will  not  be  sepai'ately  considered. 

Causation. — DiflTuse  septic  osteo-myelitis  occur.s 
under  two  distinct  conditions ;  firstly  as  a  result  of 
traumatism,  where  the  medullary  caAdty  is  opened 
and  visibly  exposed  to  septic  influences  ;  and  secondly, 
when  it  is  found  almost  uniformly  before  maturity, 
and  more  especially  in  childhood,  where  there  is  no 
open  wound,  and  no  ^*isible  passage  for  the  entrance 
of  micro-organisms.  The  first  variety  is  now  most 
frequently  met  with  in  military  surgery,  as  a  result  of 
gun-shot  wounds.     In  former  times  it  was  a  common 


it6  Manual  of  Surgery. 

result  of  compound  fractures  treated  in  civil  hospitals. 
Arising  in  children  without  visible  traumatic  cause, 
nothing  is  known  of  its  remote  etiology,  though  its 
immediate  origin  is  undoubtedly  to  be  explained  by 
the  production  of  micro-organisms.  In  some  cases  it 
is  a  manifestation  of  general  septicaemia,  and  its 
occasional  occurrence  in  several  instances  in  the  same 
hospital  ward  suggest  an  infective  origin. 

Pathology. — When  exposed  to  septic  infection 
the  marrow  in  long  bones  is  only  too  favourably  placed 
for  the  ditFusion  of  violent  inflammation.  Confined 
within  a  rigid  shell,  and  in  free  communication  from 
end  to  end  by  its  abundant  blood  and  lymph  vessels, 
the  medullary  tissue,  when  inflamed,  suffers  double 
disaster  from  the  rapidity  of  the  spread  of  the  inflam- 
mation, and  the  impossibility  of  relief  by  swelling. 
Its  soft  sensitive  tissues  are  strangulated  by  their  own 
proliferation,  and  the  bone,  cut  off  from  its  most  im- 
portant blood  supply,  suffers  death.  In  the  compact 
bone  the  incompressible  veins  may  serve  to  carry  in- 
fection to  the  system,  and  fatty  embolism  from  a 
similar  source  is  not  unknown. 

The  naked-eye  appearances  of  a  bone  affected  with 
acute  osteo-myelitis  are  striking  and  characteristic. 
The  compact  tissue  is  pink  generally,  or  in  patches ; 
the  cancellous  bone  is  of  a  bright  or  dusky  red  colour, 
and  the  marrow  is  transformed  into  a  semifluid,  often 
stinking  material,  made  up  of  pus  and  difliuent  fat, 
and  exhibiting  red  streaks  and  patches  representing 
injected  vessels  and  extravasated  blood.  In  some 
cases,  especially  in  the  non-traumatic  variety,  a  sub- 
periosteal abscess  forms.  This  is  usually  found 
where  the  compact  bone  is  thinnest,  and  its  fora- 
mina most  numerous ;  that  is  to  say,  above  the 
epiphyses,  near  the  joint.  In  this  situation  suppura- 
tive inflammation  of  the  epiphysial  cartilage  is  pecu- 
liarly liable  to  take   place,   leading  to  disjunction  of 


Os  teo-Myeli  tis. 


117 


the   epi}jliysis  from  the   shaft,  and  producing  the  con- 
dition known  as  "acute  epiphysitis." 

The  usual  termination  of  those  cases  which  do  not 
rapidly  prove  fatal  from  general 
septic  infection,  is  in  necrosis  of  the 
Avhole  bone,  or,  more  frequently,  of 
the  shaft  Ijetween  the  epiphyses 
(Fig.  25).  The  further  history  of 
the  disease  is  then  simply  that  of 
necrosis  of  bone. 

The  minute  anatomy  is  a  com- 
pound of  cellular  proliferation,  vas- 
cular blocking,  diffluence  of  fatty 
tissue,  and  general  infiltration  with 
micro-organisms.  The  bony  tissue 
proper,  suddenly  cut  oif  from  its 
nutritive  supply  and  rapidly  dying, 
has  had  no  opportunity  of  exhibit- 
ing the  signs  of  inflammation,  and 
is  essentially  unchanged. 

Sf/mptohis. — Almost  from  the 
l)eginning  diffuse  osteo-myelitis  has 
all  the  symptoms  of  a  gi-ave  disease. 
Its  onset,  often  marked  by  a  rigor, 
is  signalised  by  high  fever,  with 
profound  constitutional  disturbance, 
and  frequently  delirium.  There  is 
severe  pain  in  the  part,  which  ra- 
diates in  various  directions ;  and 
considerable  tenderness  on  pressure. 
Duskiness  of  the  skin,  with  some  Fi 
diffuse  swelling,  soon  appears,  to 
be  ra])idly  followed  by  the  forma- 
tion of  abscesses.  The  patient  either 
dies  within  a  few  days ;  or  the 
symptoms  merge  into  those  of  septi- 
caemia, which,  in  its  turn,  pro^  es  fatal ;  or  the  course 


tr.  r..— NciTdsiii  nf  the 
whole  shaft  of  theTil.ia 
between  the  epiphyses, 
as  a  result  of  acute 
osteo-myelitis.  The  dead 
hone  lies  loose  in  a  par- 
tially fornifd  shell  of 
new  peril-steal  bone. 
(Museum,  Bristol  Royal 
luflrniary.) 


ii8  Manual  of  Surgery. 

of  tlie  disease  is  diveiied  into  that  of  an  ordinary 
necrosis.  Very  rarely,  on  prompt  and  judicious 
treatment,  the  progress  of  the  disease  is  cut  short, 
and  the  patient  escapes  Avithout  either  septicaemia  or 
necrosis. 

The  distinE^uishincj  characters  of  the  disease  are  its 
rapid  onset,  and  the  high  fever  attended  v\'ith  grave 
depression,  very  rapid  pulse,  and  perhaps  delirium. 
Locally  the  ditiuseness  of  the  pain,  the  duskiness  and 
cedema  of  the  soft  tissues,  and  later  on  the  occurrence 
of  abscesses  at  central  and  outlying  points,  are  charac- 
teristic features. 

Treatment. — Immediately  on  its  being  recognised, 
diffuse  osteomyelitis  ought  to  be  treated  by  the 
making  of  one  or  more  free  openings  into  the  medul- 
lary cavity.  The  openings  are  made  after  free 
incisions  in  the  soft  parts,  with  gouge  or  trephine, 
and  must  be  large  enough  to  permit  access  to  tlie 
medulla,  and  to  j^rovide  free  drainage.  It  is  a 
question  whether  the  Ijest  treatment  would  not  be 
to  remove  the  whole  of  the  suppurating  medullary 
tissue  by  scraping,  and  wash  out  the  cavity  with  anti- 
septic fluids.  Free  incisions  are  made  through  the 
l)eriosteum  in  several  positions,  to  prevent  its  being 
completely  strijjpcd  should  subperiosteal  supjiuration 
come  on,  as  it  is  likely  to  do. 

These  measures  represent  all  that  can  be  done 
to  check  the  ravages  of  the  disease.  The  case  is 
closely  watched,  and  if  symptoms  of  septicaemia 
supervene,  amputation  is  the  only  resource.  Done 
sufficiently  early,  before  the  strength  of  the  patient  is 
gone,  amputation  in  this  disease  has  had  siifficiently 
encouraging  results.  The  treatment  proper  to  necrosis 
of  the  shaft  when  this  takes  place  is  described  under 
Necrosis. 

From  the  beginning  constitutional  treatuient  of  a 
Kuppoj-ting  or  stimulating  nature  must  be  rigorously 


Acute  Ep^piivsitis.  1 1 9 

Piiforced.  Ammonia,  ether,  bark  and  alcoliolic  stimu- 
lants, with  concentrated  and  easily  digested  nourish- 
ment, must  be  administered  in  large  and  fref|uently 
repeated  doses. 

Acute  epiphysitis. — This  is  a  form  of  acute 
osteo-myelitis,  occurring  in  chikh-en  near  the  ends  of 
the  long  bones,  and  resulting  in  disjunction  of  the 
epiphysis  from  the  shaft. 

Though,  patholotrically,  it  probably  does  not  merit 
the  position  of  a  distinct  disease,  its  clinical  features  are 
so  distinctive  and  its  importance  so  great  that  it 
generally  receives  separate  consideration. 

Causation. — Sometimes  a  blow  or  other  injury 
is  made  to  account  for  the  disease,  but  most  fre- 
quently no  such  cause  can  be  assigned.  It  is  probably 
always  septic  in  immediate  origin.  This  septicism  may 
arise  from  general  causes,  or  locally,  from  lymphatic 
infection  carried  from  a  sore  to  the  bony  marrow.  It 
is  found  almost  exclusively  in  children  or  young 
infants,  and  usually  in  such  as  are  in  feeble  general 
health. 

Pathology. — Its  pathology  is  probably  identical 
with  ordinary  septic  osteo-myelitis.  It  is  peculiar  in 
this,  that  the  inflammation  is  most  active  and  most 
destructive  where  histological  activity  is  greatest, 
namely,  in  the  parts  close  to  the  epiphysial  cartilage. 
Suppurative  inflammation  in  the  marrow  of  this 
region  causes  a  rapid  disintegration  of  the  cartilage, 
with  consequent  disjunction  of  the  epiphysis  from 
the  shaft.  The  end  of  the  shaft  is  surrounded  with 
pus  and  debris  of  medullary  tissue,  which  may 
force  its  way  into  the  contiguous  joint,  or  through 
the  skin,  or  in  both  directions.  That  the  focus  of 
the  inflammation  is  in  the  active  tissue,  abutting  on 
the  epiphysial  cartilage,  there  need  be  no  dispute  ;  that 
it  starts  in  the  cartilage  itself,  or  in  the  epiphysis,  as  is 
maintained  by  some  surgeons,  is  exceedingly  doubtful. 


I20  Manual  Of  Surgery. 

Symptoms.  —  As  already  stated,  the  disease  is 
found  in  unhealthy  children  during  the  first  few 
months  of  existence.  It  is  situated  most  frequently 
in  the  femur  at  the  hip  joint,  and  with  diminishing 
frequency  at  the  knee  joint,  the  shoulder,  the  elbow, 
and  the  ankle.  Locally  it  presents  the  ordinary  signs 
of  an  acute  inflammation  rapidly  going  on  to  suppura- 
tion, and  at  a  very  early  stage  affecting  the  joint. 
The  child  is  evidently  seriously  ill  with  high  fever, 
and  great  depression  of  the  vital  powers.  When  the 
disease  has  existed  for  a  few  days,  grating  on  move- 
ment with  perhaps  undue  mobility,  marking  dis- 
junction of  the  epiphysis,  will  probably  be  found.  The 
disease  rapidly  progresses,  and  may  be  fatal  within 
two  or  three  days.  In  cases  that  are  not  rapidly 
fatal  abscesses  form  and  bui'st,  and  recovery  may  take 
place  after  a  tedious  illness.  The  bone  may  become 
united,  though  its  future  growth  is  stunted.  As  the 
joint  is  implicated  at  a  very  early  stage  of  the  disease, 
it  is  easy  to  mistake  it  for  a  pure  joint  aflTection ;  in- 
deed, it  is  frequently  described  among  diseases  of  joints. 

Treatment. — To  support  the  child's  strength  and 
to  provide  free  exit  for  the  pus  are  the  leading  indi- 
cations for  treatment.  Early  and  free  incisions,  with 
sufficient  drainage  and  antiseptic  dressings,  give  the 
best  chance  of  cure.  Indeed,  with  such  treatment,  it 
is  surprising  to  find  how  great  the  recuperative  power 
sometimes  is.  The  disjoined  fragment  unites  firmly 
to  the  shaft,  the  inflammation  in  the  joint  subsides, 
and  the  articulation  may  be  left  with  free  movement. 
If,  after  such  treatment,  signs  of  improvement  are  not 
apparent,  amputation  above  the  disease  is  the  only 
resource  left. 

Necrosis. — By  necrosis  of  bone  is  understood  a 
death  of  the  wliole  or  some  part  of  the  bone  without 
marked  alteration  in  its  structure,  and  following  one 
or  other  of  the  varieties  of  acute  inflammation. 


N'ecrosis. 


121 


Causation. — The  immediate  cause  of  necrosis  is 
stoppage  of  the  circulation, 
either  through  the  vessels 
being  torn  by  injury,  or 
from  their  becoming  Ijlocked 
as  a  result  of  the  inflamma- 
tory process.  The  remote 
causes  are  those  of  the  form 
of  inflammation  which  gave 
rise  to  it.  An  acute  form  of 
necrosis  is  liable  to  follow 
any  of  the  specific  fevers, 
especially  scarlet  fever ; 
scrofula  and  syphilis  predis- 
pose to  the  more  chronic 
forms.  Among  local  causes, 
injuries,  as  blows,  Avounds, 
or  amputations,  hold  the 
first  place.  A  peculiar  form 
of  necrosis  in  the  lower  jaw 
is  found  among  workers  in 
phosphorus.  In  old  people 
a  variety,  analogous  to  senile 
gangrene  of  the  soft  tissues, 
and  known  as  senile  necrosis, 
is  met  with. 

Pathology. — Necrosis  has 
already  been  mentioned  as  a 
])ossible  termination  of  the 
three  leading  varieties  of 
inflammation  in  bone. 
Generally  speaking  the  va- 
riety of  necrosis  is  deter- 
mined by  the  nature  of  the 
inflammation.  Thus  perios- 
titis, as  a  rule,  causes  a 
superficial   necrosis  of  the   outer   layers   of   compact 


Figr.  2fi.— Tibia  "howinsr  in  its  ui>pt'r 
third  siipcrfl.ial  necrosis  ;  in  its 
middle  third  necrotic  caries  (not 
■well  shown  in  drawing)  ;  and  in  its 
lower  third  total  necrosis  sur- 
rounded by  an  almost  complete 
involucre  of  new  l)onc.  (Museum, 
Bristol  Royal  Infirmary .") 


122  Manual  of  Surgbiry. 

bone  {j)eriplieral  necrosis)  ;  osteitis  most  frequently 
results  in  death  of  a  portion  of  the  cancellous  or 
compact  tissue  {central  necrosis) ;  while  endosteitis,  if 
acute,  causes  death  of  the  whole  shaft  {total  necrosis). 

In  every  case  the  immediate  cause  of  necrosis  is 
thrombosis  in  the  blood-vessels,  induced  either  by 
injury  or  inflammation.  The  piece  of  dead  bone  thus 
cut  off  from  its  vital  connections  is  essentially  a 
foreign  body,  and  acts  as  an  irritant  upon  the  sur- 
roundinsf  tissues,  causing  the  formation  of  an  abscess. 
The  suppurative  process  thus  set  up,  with  the  con- 
comitant separation  and  disintegration  or  extrusion 
of  the  bone,  along  with  certain  conservative  processes 
in  the  outlying  tissues,  constitute  the  chief  features  of 
the  disease. 

In  detail  the  pathological  process  is  as  follows. 
The  outlines  of  the  dead  bone  are  marked  ofl:'  by  k^ 
limiting  area  of  thrombosis  in  the  living  tissue. 
Behind,  up  to,  and  in  this  thrombotic  area,  the 
ordinary  process  of  rarefying  osteitis  is  set  up.  The 
inflammation  is  most  active  in  the  immediate  proxi- 
mity of  the  dead  bone,  and  here  the  rarefaction  soon 
proceeds  to  complete  absorption,  thus  setting  the 
dead  bone  free  from  the  living.  The  granulations 
which  sprout  from  the  rarefied  bone  now  act  upon  the 
dead  bone  as  well,  causing  its  absorjjtion  or,  rather, 
disintegration.  The  gap,  gradually  increased  between 
the  living  and  the  dead  and  now  loosened  bone,  is 
occupied  by  granulation  tissue,  bony  detritus,  and 
pus. 

Concomitantly  there  goes  on  a  conservative  de- 
velopment of  new  bone.  This  takes  place  in  the 
periosteum,  in  the  granulation  tissue  which  occupies 
the  medullary  canal,  and  in  the  rarefied  compact  bone 
which  lies  around.  The  periosteum  in  such  a  case 
will  have  been  stripped  from  the  bone  and  elevated 
by  the  burrowing  pus,  so  that  there  is  always  a  little 


Necrosis. 


123 


ypaco  between  the  periosteal  new  bone  and  the  dead 
portion.  The  new  growth  starts  in  the  periosteum, 
coverinc:   the  livini;  bone   at  some  distance  from  the 


Fig  27. — Diagrammatic  Eepresentation  of  tlie  Process  of  Neci'osis. 
The  drawing  is  supposed  to  show  a  slice  cut  lougitudinally 
through  a  long  bone  which  has  suffered  total  necrosis  of  part  of  the 
shaft. 

aa.  Shaft  of  healthy  hone  ;  hb,  necrosed  portion  ;  cc,  areolar  new  bone  developed 
under  the  pcrinistcuni  and  in  the  mediillai-y  canal ;  dd.  pralnllation^^ 
pproutinff  from  the  new  areolar  hone  surrounding  the  necroj^ed  Jlortl<ln^» 
luiing  the  sinuses  (e^  and  marking  the  limits  of  the  extension  of  the  new  hone 
up  the  medullary  caual  (/) ;  s,  skin. 


line  of  necrosis,  and  in  the  course  of  time,  with  the 
exception  of  some  openings  through  which  pus  is 
discharged,  completely  ensheaths  the  loosened  necrosed 


124  Manual  of  Surgery. 

bone  or  sequestrum,  as  it  is  called.  In  the  granula- 
tion tissue  which  replaces  the  medulla  in  the  hollow 
of  the  shaft  new  bone  is  also  developed,  which  may 
not  only  completely  plug  the  opening,  but  extend 
along  the  cavity  in  the  necrosed  bone  till  the  ends 
meet,  forming  an  internal  callus  which  is  covered 
by  the  dead  bone  as  a  sort  of  ferrule.  The  new 
bony  growth  in  the  surrounding  compact  bone, 
thinned  by  rarefying  osteitis,  is  of  the  nature  of  an 
osteo-plastic  osteitis  filling  up  enlarged  cavities  rather 
than  increasing  general  bulk. 

The  changes  may  be  seen  from  a  study  of  the  ac- 
companying diagram  (Fig.  27).  It  will  be  noticed  that 
the  dead  bone  lies  bathed  in  pus,  in  an  abscess  cavity 
which  is  lined  by  gran\ilations  mostly  springing  from 
young  areolar  bone.  This  pus,  containing  a  large 
amount  of  bone  salts,  reaches  the  surface  through 
openings  called,  in  the  bone,  cloacse  ;  and,  in  the  soft 
tissues,  sinuses  or  fistulae.  The  dead  bone  is  now 
known  as  a  sequestrum,  and  the  process  of  separation 
as  exfoliation.  The  abscess  cavity  may  increase  or 
diminish  in  size  round  the  steadily  diminishing 
sequestrum.  As  a  rule  the  new  bone  grows  in  upon 
the  sequestrum  more  slowly  than  the  sequestrum 
diminishes,  so  that  the  longer  the  case  has  lasted,  the 
more  loosely  does  the  sequestrum  lie  in  its  cavity. 
Occasionally,  however,  the  growth  of  new  bone  is  so 
exuberant  that  the  sequestrum  is  embedded  in  it,  and 
fixed  so  as  to  become  almost  immovable  (Fig.  28). 
Sometimes,  again,  the  cavity  around  the  sequestrum 
seems  to  enlarge  instead  of  diminishing. 

Symptoms. — The  symptoms  of  necrosis  follow  an 
aggravation  of  the  symptoms  of  the  inflammation 
in  periosteum,  bone,  or  medulla  which  gave  rise  to  it. 
The  pain,  fever,  and  swelling  increase  till  evidences  of 
suppuration  appear  with  formation  of  an  abscess, 
wliich  bursts  through  the  skin  if  it  is  not  opened.     A 


Necrosis.  125 

probe  introduced  through  the  opening  so  made  strikes 
upon  bare  compact  bone  of  normal  density.  The 
signs  of  acute  inflammation  now  subside,  and  the 
abscess  opening  becomes  a  fistula  surrounded  by  red 
granulations,  and  discharging  quantities  of  liquid 
yellow  pus.  Most  frequently  there  are  two  or  more 
such  fistulse.  A  probe  introduced  along  one  or  other 
of  these  openings  strikes  on  the  bare  sequestrum, 
which  may  or  may  not  be  loose,  according  to  the 
duration  of  the  case. 

Necrosis  is  most  liable  to  be  confounded  with 
caries.  Necrosis  is  distinguished  most  readily  by  the 
hardness  and  smoothness  of  the  bare  bone  struck  by 
the  probe  introduced  through  the  fistula ;  in  caries  the 
bone  is  rough,  and  so  soft  that  the  probe  may  be 
pushed  through  it.  In  necrosis,  the  granulations,  red 
and  healthy-looking,  pout  at  the  openings,  and  the 
surroundinof  skin  is  of  normal  colour  and  consistency  ; 
in  caries  the  openings  are  small,  not  usually  filled  with 
granulations,  and  the  surrounding  skin  is  undermined 
and  reddened.  The  discharge  in  necrosis  is  usually 
yellow  healthy-looking  pus ;  in  caries  it  is  watery, 
pale,  and  unhealthy.  In  necrosis  there  is  considerable 
thickening,  rough  and  unyielding,  caused  mainly  by 
the  periosteal  new  bony  gro\^i:h ;  in  caries,  if  there  is 
any  thickening,  it  is  caused  by  cedematous  swelling  of 
the  soft  tissues,  or  by  mere  expansion  of  the  bone, 
and  is  not  usually  nodular  on  the  surface. 

Treatment.  —  The  indications  in  treatment  are 
to  get  rid  of  the  sequestrum,  and  to  support  the 
strength  of  the  patient  while  the  tedious  process  of 
suppuration  is  going  on.  For  the  latter,  fresh  air 
with  out-door  existence  where  possible,  and  the 
administration  of  cod-liver  oil  and  iron  with  plenty  of 
good  food,  are  the  chief  requisites.  Any  constitutional 
dyscrasia,  such  as  scrofula  or  syphilis,  must  be  treated 
by  their  propei*  remedies. 


126 


Manual  of  Surgery. 


Locally,  the  treatment  is  simply  removal   of  the 
sequestrum.     If  the  dead  bone  is  small  and  supei-ficial, 

it  may  escape  through 
the  sinus  or  be  simply 
lifted  out  of  its  bed 
before  the  encapsuling 
new  bone  is  developed. 
But  as  the  new  bone 
closes  round  the  seques- 
trum, the  chances  of 
spontaneous  removal  di- 
minish, and  some  opera- 
tion is  usually  necessary 
to  take  it  away  (Fig.  28). 
Sequestrotomy,  as  the 
operation  for  removal  of 
a  sequestrum  has  been 
called,  is  not  usually 
performed  till  the  dead 
is  freed  from  the  living 
bone  and  lying  loose  in 
its  bed.  In  some  cases 
of  limited  and  super- 
ficial necrosis  the  seques- 
trum may  be  readily 
removed  by  forceps  with 
or  without  a  simple  skin 
incision.  In  most  cases, 
however,  a  more  com- 
f  ^  plicated    proceeding,  in- 

f  volving  division  of  the 

J  new  bone,  is  necessary. 

Fi>.  28.-.V ..,.,,,,.,1  withtotniNe-  ^^^  ^u  Ordinary  case 

rroisis  of  ilie  iuiil(ilc  third  of  its  Shaft.  +Vi<i    rm^t^va^-imi     ia    qo     frkl- 

The    eiish.athing  new   bone    is   sawn  ^"*^    opcidtlOU    lb    ah     lOl 

through  at  the  middle  to    sliow    the  lr»vi7e  •    TIia    liinl*    ia    toii 

Hcuiiustnmi.    Several  ch)acie  are  visi-  i^wft  .     iiic    iiuiu    i>,    leii- 

bh;.    This  femur  is  from  tlie  first  case  rlpv<^/l     Vilnnrnp««      \\\r    (Aa. 

of  ami-utatinn   at  th.-  hip   joint    jicr-  tieieU     DlOOClieSS      Dy    eie- 

formed  in  Knplaiid  in  1814.     (Museum,  vnfinii    rw    liv     ^^,cmirr>l-»'a 

Bristol  uujaniiflrmary.)  \auon  or  oy  JiiSmarcn  S 


Necrosis.  127 

method,  and  a  rubljer  tourniquet  applied.  The 
most  convenient  sinus  is  selected,  and  the  under- 
lying cloaca  exposed  by  suitable  incision  through 
the  soft  parts.  If  the  cloaca  is  large  enough  to 
admit  of  its  passage,  the  sequestrum  is  seized  by  a 
special  forceps  called  necrosis  forceps,  and  removed. 
If  the  cloaca  is  not  large  enough,  it  is  enlarged  by 
gouge  or  trephine,  and,  at  the  same  time,  the  extrac- 
tion of  the  sequestrum  may  be  facilitated  by  dividing 
it  in  the  middle  by  bone  forceps  and  removing  it  in 
lialves. 

The  granulations  lining  the  cavity  from  which 
the  sequestrum  has  been  removed  are  scraped  out, 
and  the  whole  cavity  swabbed  or  irrigated  with  a 
strong  antiseptic  fluid.  If  there  is  bleeding  the  cavity 
must  be  plugged  with  strips  of  boracic  lint,  or  of  lint 
sprinkled  with  iodoform,  or  some  such  similar  dress- 
ing. 

If,  as  frequently  happens  in  cases  of  total  necrosis, 
the  new  bone  is  small  in  amount  and  liable  to  become 
fractured,  a  splint  must  be  applied  and  worn  for  some 
weeks.  In  most  cases  rest  and  elevation  of  the  part 
will  be  advisable,  though  it  will  rarely  be  necessary 
to  confine  the  patient  to  bed. 

In  cases  of  extensive  necrosis  where  septic  absorp- 
tion with  high  fever  are  rapidly  sapping  the  patient's 
health,  and  where  an  immovable  sequestrum  with 
advanced  suppuration  in  the  soft  parts  render  mere 
sequestrotomy  an  operation  not  likely  to  be  successful, 
amputation  may  be  called  for.  Accidental  injury  to 
vessels  or  other  structures  by  an  extended  sequestrum 
may  be  a  reason  for  amputation. 

Quiet  necrosis,  or  necrosis  without  suppura- 
tion, is  the  name  given  to  a  form  of  necrosis  in  which 
the  signs  of  inflammation  are  slight  or  absent,  and  the 
sequestrum  either  disappears  or  is  encapsuled  without 
the  formation  of  an  abscess  which  opens  externally. 


123  Manual  of  Surgery. 

The  dead  bone  is  passively  tolerated  or  quietly  re- 
moved without  any  external  signs.  This  form  of 
necrosis  is  very  rare. 

Phosphorus  necrosis  of  the  jaws  is  a  pecu- 
liar form  of  necrosis  which  attacks  the  jaws  of  workers 
in  phosphorus.  The  immediate  cause  is  supposed  to 
be  the  action  of  phosphorous  acid  on  bone  that  abuts 
on  carious  teeth.  An  osteitis  is  thus  set  up  which 
spreads  outwards  under  the  periosteum,  and,  becom- 
ing suppurative,  elevates  that  tissue  from  the  bone, 
thus  causing  its  death.  In  this,  as  in  other  forms  of 
necrosis  of  the  jaws,  there  is  always  an  excessive 
development  of  new  bone  around  the  sequestrum, 
rendering  the  process  of  cure  tedious  and  difficult. 

Care  in  seeing  to  the  cleansing  of  the  teeth,  and 
the  use  of  the  red  amorphous  phosphorus  instead  of 
the  yellow  variety,  have  been  found  to  diminish  the 
susceptibility  to  the  disease. 

Diseases  of  Nutrition. 

A  small  and  comparatively  unimportant  class  of 
diseases  of  bone,  depending  neither  on  actual  inflam- 
mation nor  on  specific  constitutional  dyscrasia,  are 
described  as  diseases  of  nutrition.  They  may  be  sub- 
divided into  hyperiro'phic  and  atrojyhic  varieties. 

Diseases  of  Nutrition  attended  with 
Hypertrophy. 

Simple  hyi>ertrophy  of  bone. — Most  cases 
of  enlargement  of  bone  originate  in  inflammation 
from  injury.  Examples  of  simple  overgrowth  are 
best  seen  in  cases  where  the  ordinary  pressure  to 
which  a  long  bone  is  exposed  has  been  removed.  The 
general  increase  in  length  which  frequently  occurs 
when  a  young  person  is  confined  to  bed  for  a  time 
is  an  example  of  this  sort.  Another  example  may 
be   seen   in   the    increase  of  length   which  a  radius, 


Osteitis    Deformans.  129 

dislocated  at  its  upper  extremity  and  unreduced,  may 
undergo.  In  the  rare  cases  of  simple  overgrowth  of 
one  or  more  fingers  or  toes,  or  even  of  a  whole  limb, 
the  bone  simply  participates  in  the  general  hyper- 
trophy. It  is  doubtful  if  the  enlargement  which 
follows  rickets  is  to  be  regarded  as  simple  hyper- 
trophy. 

Osteitis  deforiiiaus  (Paget). — This  is  a  rare 
and  extraordinary  affection  of  the  bones,  probably 
inflammatory,  attended  with  increase  of  bulk  and 
frequently  with  distortion  of  shape.  It  occurs  speci- 
ally in  persons  after  the  prime  of  life,  is  accompanied 
with  considerable  pain,  and  usually  attacks  several 
bones  simultaneously  or  in  succession.  No  specific 
cachexia  has  been  found  associated  with  the  disease, 
and,  though  it  may  last  over  a  number  of  years,  it  may 
produce  little  or  no  impairment  of  health.  Locally 
the  bone  is  enlarged  in  all  its  dimensions,  rarefied  in 
its  compact  portions,  and  thickened  and  roughened 
under  the  periosteum.  The  clinical  features  are  elon- 
gation  of  the  limbs  from  the  bony  overgrowth,  and 
distortion  in  the  shape  of  the  spine,  pelvis,  skull  and 
thorax,  as  well  as  of  the  limbs,  from  the  weakness 
caused  by  rarefaction. 

No  treatment  has  been  found  of  benefit.  The 
disease,  after  continuing  for  years,  may  become  spon- 
taneously arrested,  leaving  the  bones  increased  in 
bulk  and  in  density.  In  a  few  cases  malignant 
growths  have  appeared  in  the  hypertrophied  bones. 

Leoutiasis  ossea  (Virchow). — This  is  a  curious 
disease  limited  to  the  bones  of  the  skull  and  face, 
and  marked  by  an  increase  in  their  thickness,  so  great 
that  the  patient  is  usually  killed  by  compression  of 
the  brain  or  blocking  of  the  nose  and  pharynx.  The 
condition  seems  to  be  an  enormous  overgrowth,  with 
increased  sponginess  of  the  diplbe.  It  always  com- 
mences in  early  life.  Billroth  speaks  of  a  similar 
J— 21 


130  Manual  of  Surgery. 

affection  found  in  the  flat  bones  generally,  and  likens 
it  to  elephantiasis  of  the  skin.  The  cause  is  unknown, 
and  all  treatment  has  been  ineffectual 

Diseases  of  Nutrition  attended  with  Atrophy. 

Simple  atropliy. — Any  diminution  of  nutritive 
supply  may  be  followed  by  simple  atrophy  of  bone. 
In  old  age  thinning  of  the  compact  bone  and  rarefac- 
tion of  the  cancellous  portions  takes  place  in  the  bones 
generally,  rendering  them  liable  in  favourable  locali- 
ties, such  as  the  neck  of  the  femur,  to  fracture  from 
slight  causes.  Interference  with  the  blood  supply,  as 
in  cases  of  fracture  where  the  medullary  artery  is  torn 
through ;  destructive  inflammation  of  the  epiphysial 
cartilage  in  young  growing  bones ;  diminution  of 
function,  as  in  anchylosis  of  the  elbow,  and  all  such 
influences,  are  followed  by  bony  wasting. 

Fatty  atrophy. — In  all  cases  of  atrophy  of  bone 
yellow  marrow  more  or  less  completely  replaces  red 
marrow.  In  health,  where  there  is  no  cancellous 
tissue,  as  in  the  centre  of  a  developed  long  bone, 
the  marrow  is  almost  pure  fat.  It  is  the  same  in 
disease  ;  as  the  cancellous  bone  disappears  the  marrow 
in  its  meshes  becomes  fatty.  This  condition  is  specially 
seen  in  the  long  bones  around  joints  that  have  been 
long  inflamed  and  out  of  use.  In  such  cases  the 
red  marrow  may  have  completely  disappeared,  its 
place  being  taken  by  a  tissue  that  is  little  more  than 
fat ;  the  compact  bone  is  reduced  to  a  mere  shell, 
and  the  cancellous  bone  is  a  delicate  and  friable  tissue 
that  can  be  cut  with  the  knife  and  crushed  between 
the  Angers.  The  condition  is  seen  in  its  most  typical 
form  in  the  bones  of  the  thigh  and  leg  after  long- 
standing strumous  disease  of  the  knee  joint. 

Frag^ilitas  ossiuiii. — Though  this  term  is  appli- 
cable  to  .several  conditions  associated  with  diminished 
strength  of  bone  causing  a  tendency  to  fracture  on 


Scrofula  of  Bone.  131 

slight  provocation,  it  lias  also  a  special  significance  as 
applied  to  children.  A  child  may  occasionally  be 
found  who  has  sufiered  fracture  of  almost  every  bone 
in  the  limbs  and  not  a  few  of  the  body  before  it  has 
reached  the  tenth  year.  Running  on  a  stone  pave- 
ment, playing  leap-frog,  striking  a  smart  blow,  have 
been  known  to  cause  fracture  in  such  cases.  Some  of 
the  bones  may  have  been  broken  several  times  in  suc- 
cession^ uniting  in  the  ordinary  way  and  with  average 
rapidity.  No  cause  has  been  discovered  beyond  an 
excessive  tenuity,  with  perhaps  increase  of  density  in 
the  bony  tissues.  The  children  are  usually  fragile, 
but  not  diseased. 

A  brittleness  of  bones  may  be  caused  by  various 
diseases,  such  as  aneurism  of  bone,  new  growths,  ne- 
crosis, osteo-malacia,  and  atrophy. 

Constitutional  Diseases  of  Bone. 

Under  this  heading  are  described  a  number  of  affec- 
tions of  bone  which  are  associated  with  definite  and 
palpable  constitutional  disease,  and  which  may  appear 
in  any  or  every  bone  of  the  body.  They  are  scrofula, 
with  its  ally  tubercle,  syphilis  and  osteo-malacia. 

Scrofiila  and  tubercle  in  bone. — The  rela- 
tions of  scrofula  to  tubercle  cannot  here  be  discussed. 
The  want  of  definiteness  which  for  years  has  attached 
to  the  meaning  of  these  terms  is  seen,  perhaps,  at  its 
worst  in  diseases  of  bones.  At  present  the  tendency 
is  to  consider  them  pathologically  identical,  giving 
them  the  same  causation  (the  bacillus  tuberculosis), 
and  combining  the  wide  clinical  divergencies  in  the 
assumption  that  they  are  different  stages  in  the  same 
afiection.  (^See  Arts,  on  Scrofula  and  Disease  of  Joints.) 

From  a  purely  clinical  point  of  view  we  can 
distinguish  at  least  three  forms  of  disease  of  bone, 
scrofulous  or  tubercular,  as  we  may  prefer  to  name 
them  which  may  be  described  under  this  head.    These 


132  Manual  of  Surgery. 

are  the  miliary  tubercle ;  the  mass  of  degenerate  cheesy 
material  often  described  as  caseating  tubercle ;  and 
that  form  of  low  rarefying  osteitis  usually  described 
as  scrofulous  caries. 

The  miliary  tubercle  or  nodule  occurs  in  the 
marrow  lying  in  cancellous  bone,  either  as  a  part  of 
general  miliary  tuberculosis  or  as  started  by  local 
infection  from  a  mass  of  caseating  inflammatory  ma- 
terial. As  met  with  here,  its  structure  and  beha\T.our 
are  the  same  as  elsewhere.  As  a  part  of  general 
miliary  tuberculosis  it  is  a  fatal  disease  ;  as  origi- 
nating in  infection  from  caseous  products  it  may  be 
either  the  forerunner  of  general  tuberculosis  or  the 
indication  of  advancing  and  grave  local  disease  in  the 
bone. 

The  mass  of  degenerate  imflammatory  material, 
known  as  caseating  tubercle,  is  also  chiefly  met  with 
in  the  cancellous  ends  of  the  long  bones.  In  structure 
and  behaviour,  as  well,  in  all  probability,  as  in 
pathological  origin,  such  masses  are  closely  allied  to 
those  met  with  in  scrofulous  lymphatic  glands.  They 
may  exist  for  prolonged  periods,  producing  but  few 
symptoms,  and  any  change  that  they  undergo  is  likely 
to  be  further  retrogressive.  The  importance  of  such 
collections  is  enhanced  from  their  proximity  to  joints, 
and  their  tendency  to  implicate  these  in  their  de- 
generate changes.  Such  masses  contain  in  their 
substance  little  or  no  bony  tissue.  The  osteitis  which 
l)recedcd  it  will  have  greatly  thinned,  or  completely 
destroyed  the  cancellated  trabeculse. 

The  best  known  and  by  far  the  most  important 
form  of  scrofulous  bone  disease  is  the  variety  of  caries 
to  which  it  gives  its  name.  Indeed,  most  examples 
of  caries  own  scrofula  as  a  predisposing  cause.  None 
of  the  bones  are  free  from  it,  though  it  has  decided 
jnedilections  for  certain  sites.  It  is  found  most 
frequently  in  the  bones  of  the  hands  and  feet,  in  the 


Scrofula  of  Bone.  133 

bodies  of  the  vertebrae,  and  in  the  cancellous  ends  of  the 
long  bones.  As  caries  of  the  carpus  and  the  tarsus 
among  the  young  of  the  poorer  classes,  it  is,  perhaps, 
the  most  common  of  all  diseases  of  bone,  running  a 
very  slow  course,  attacking  one  bone  after  the  other, 
rarely  capable  of  cure,  and  ultimately  demanding 
amputation.  As  "  strumous  dactylitis  "  in  children, 
it  attacks  the  long  bones  of  the  hands  and  feet, 
expanding  the  compact  shell,  and  transforming 
the  medullary  contents  into  fungating  granulation 
material.  Attacking  the  bodies  of  the  vertebrae,  it  is 
■well  known  as  Pott's  disease,  or  angular  curvature  of 
the  spine.  In  the  ends  of  the  long  bones  it  has  a 
special  importance,  as  being  a  frequent  cause  of  one 
of  the  most  intractable  forms  of  chronic  joint  disease. 

In  these  instances  the  affection  lies  in  the  medullary 
cavity.  Sometimes,  however,  it  appears  under  the 
periosteum  as  a  "  strumous  node,"  producing  an  abscess 
and  superficial  caries. 

Symptoms.  —  The  symptoms  of  simple  miliary 
tubercle  in  bone  are  those  of  general  miliary  tuber- 
culosis. A  number  of  miliary  nodules  around  a 
caseating  focus  produce  no  symptoms  beyond  its 
cause.  A  mass  of  tubercular  caseated  material 
usually  produces  slight  or  no  symptoms  till  it  breaks 
up  and  suppurates,  when  the  symptoms  are  simply 
those  of  scrofulous  caries. 

In  scrofulous  caries  the  onset  is  uncertain  and  the 
progress  slow.  Otherwise,  the  symptoms  are  simply 
those  of  ordinary  caries,  already  described,  plus  the 
signs  of  the  scrofalous  diathesis.  In  strumous 
dactylitis  the  disease  is  somewhat  peculiar  in  causing 
expansions  of  the  bony  shell,  forming  a  chronic 
abscess  within  the  bone,  which,  even  after  an  exit  for  its 
contents  has  been  provided,  may  continue  to  discharge 
indefinitely.  Elsewhere  perforation  of  the  compact  bone 
usually  takes  place  before  expansion  is  perceptible. 


134  Manual  of  Surgery. 

Treatment.  —  Constitutionally  the  scrofulous  ele- 
ment is  treated  by  tlie  ordinary  remedies.  Locally, 
before  suppuration  has  commenced,  counter-irritation 
by  blisters  or  the  actual  cautery,  the  application  of 
Scott's  dressing,  or  the  oleate  of  mercury,  with  elastic 
compression  by  rubber  bandage,  have  been  of  benefit. 
Most  frequently,  however,  suppuration  takes  place, 
and  our  efforts  are  then  directed  to  the  removal  of 
the  funsatinor  granulations  with  the  carious  bone 
after  the  manner  above  described.  In  disease  of  the 
tarsus  or  carpus,  excision  or  amputation  is  usually 
necessary.  In  strumous  dactylitis  amputation  is 
usually  performed ;  but  if  a  good  portion  of  the 
expanded  bony  shell  is  removed,  with  the  attached 
skin,  and  the  cavity  dressed  from  the  bottom  by 
some  stimulating  antiseptic  material,  cure  may  be  got 
without  amputation.  In  every  case,  before  perforation 
has  taken  place,  Listerism  in  all  its  details  will  be 
attended  with  the  best  results. 

Syphilitic  diseases  of  bone.  —  Syphilitic 
diseases  of  bone  may  be  considered  under  two  heads, 
as  they  originate  (1)  from  acquired  syphilis,  or  (2) 
from  congenital  sypliilis.     {See  Art.  on  Syphilis.) 

Osseous  lesions  in  acquired  syphilis. — 
These  occur  as  periosteal  inflammations,  frequently 
resultinor  in  caries  and  necrosis,  and  as  chronic  osteitis 
producing  general  thickening.  They  are  recognised 
as  tertiary  manifestations. 

Pathology.  —  Syphilitic  bony  disease  is  most 
frequently  met  with  as  localised  collections  of  small- 
celled  inflammatory  material  between  the  periosteum 
and  compact  bone.  Such  collections  may  be  regarded 
as  gummatous  tumours.  They  elevate  the  periosteum, 
forming  hard,  rounded  elevations,  and  are  known  as 
2)eriosteal  nodes.  Under  appropriate  treatment  these 
nodes  may  disappear,  but  frequently  they  go  on 
increasing  in  size  ;  the  lowly  organised  inflammatory 


Syphilis  of  Boxe.  135 

material  breaks  down  and  suppurates,  forming  a 
gummatous  ulcer  with  sluggish  granulations,  which 
extend  some  way  into  the  bone,  rarefying  and  dis- 
integrating it.  This  is  syphilitic  caries.  In  bones 
which  depend  mainly  upon  the  periosteum  for  their 
blood  supply,  as  the  fiat  bones  of  the  skull  or  face, 
such  elevation  of  the  periosteum  by  gummatous 
material  may  kill  the  bone  by  deprivation  of  nourish- 
ment, and  the  result  is  syphilitic  necrosis.  The  least 
common  form  of  syphilitic  bony  disease  is  where  there 
is  a  general  low  form  of  diffuse  inflammation,  resulting 
in  a  hypertrophic  thickening  of  the  mass.  This  is 
known  as  syphilitic  osteitis  or  sclerosis. 

Symptoms. — In  addition  to  the  ordinary  history 
of  syphilitic  infection,  certain  local  peculiarities 
suggest  the  specific  origin  of  these  complaints.  The 
periostitic  node  is  found  most  frequently  on  the  tibia, 
the  ulna,  and  the  clavicle,  and  appears  under  the  skin 
as  a  hard,  rounded,  and  tender  swelling.  Pain  is 
almost  uniformly  worst  at  night.  If  the  swelling 
increases  much  in  size  and  is  about  to  suppurate,  it 
extends  chiefly  at  the  margins,  leaving  a  soft,  often 
depressed,  area  in  the  centre  covered  with  purple 
congested  skin.  When  the  skin  breaks,  the  unhealthy 
granulations  lie  in  a  bed  of  carious  bone,  which  is 
diagnosed  in  the  ordinary  Avay.  On  the  skull,  and 
especially  on  the  forehead,  syphilitic  bony  disease 
manifests  itself  usually  as  small  areas  of  necrosis, 
leaving,  w^hen  the  dead  bone  is  removed,  similar 
punched-out  ulcers,  which  extend  through  the  outer 
table,  and  frequently  the  inner  table  as  well.  In  the 
neighbourhood  of  such  ulcers  that  have  been  of  any 
duration,  there  is  usually  some  considerable  amount 
of  bony  thickening.  The  middle  line  of  the  hard 
palate  is  frequently  aflected,  causing  the  fonnation  of 
an  opening  between  the  nasal  and  oral  ca\'ities.  The 
nasal    bones  and  parts   of   the  jaws   are   also    often 


136  Manual  of  Sukgeky, 

involved.  Nodes  may  grow  inwards  on  the  brain, 
producing  cerebral  symptoms.  In  syphilitic  sclerosis, 
which  by  preference  affects  the  long  bones,  shifting 
pains,  with  diffuse  thickening,  are  the  only  local  signs. 

In  suppurative  syphilitic  bone  disease  the  dis- 
charges are  usually  foetid  and  the  wounds  foul  and 
unhealthy.  In  necrosis  of  the  bones  of  the  face  the 
foetor  is  met  with  at  its  worst. 

Treatment. — The  treatment  proper  to  the  consti- 
tutional disease  is  to  be  fully  and  systematically 
carried  out.  Till  the  constitutional  treatment  has 
had  a  fair  trial,  no  operative  treatment  is  to  be 
instituted.  Not  only  nodes,  but  even  collections 
of  semipurulent  material  may  melt  away  under 
the  administration  of  iodide  of  potassium  or  mer- 
cury, or  both  combined  or  alternated.  If  an  abscess 
must  be  evacuated,  it  must  be  done  through  as 
small  an  opening  as  possible,  as  there  is  a  tendency 
for  large  sluggish  sores  to  follow  injury  to  the  skin. 
Local  measures  for  the  removal  of  carious  or  necrosed 
bone  need  not  be  carried  out  with  so  much  energy  in 
syphilitic  as  in  strumous  disease.  For  the  dressing  of 
the  open  sores  nothing  is  better  than  iodoform. 
Surgical  cleanliness  in  its  most  perfect  form  must  be 
minutely  observed. 

Osseous  lesions  in  congenital  s>i>liilis. — 
Tliese  are  met  with  chiefly  in  two  forms  :  (1)  as 
atrophic  changes  in  the  bones  generally,  and  in 
special  situations;  (2)  as  hypertrophic  growths 
(nodes  or  osteophytes)  in  various  situations,  but  more 
especially  in  the  skull. 

Atrophic  changes  in  congenital  syphilis 
are  found  most  frequently  in  the  bones  of  the  skull, 
in  the  long  bones,  and  in  the  teeth. 

In  the  skull  the  disease  shows  itself  in  very 
young  children  as  a  wasting  of  the  bones  at  the  sites  of 
decubitus,  that  is  to  say,  behind  the  eminence  of  the 


Syphilis  of  Bone.  137 

parietal  bone,  in  the  occipital  bone,  and  in  tlie 
squamous  portion  of  the  temporal.  The  bone  is  either 
much  thinned,  so  as  to  become  like  parchment,  or  is 
transformed  into  a  gelatinous  material,  in  which  no 
bony  tissue  can  be  felt.  This  condition  is  known  as 
cranio-tabes.     {See  Art.  on  Syphilis.) 

In  the  long  bones  the  clianges  appear  usually  in 
the  neighbourhood  of  the  epiphysial  cartilage,  and 
consist  mainly  in  an  excessive  deposit  of  lime  salts  in 
the  cartilaginous  matrix,  along  with  an  overgrowth  of 
the  young  medullary  tissue,  which  absorbs  and  replaces 
the  bone.  The  bone  is  thus  made  at  once  brittle  and 
soft,  liable  to  bend  in  bulk  or  to  break  in  portions. 
It  sometimes  results  in  suppuration.  When  the 
disease  is  at  its  height  the  infant  will  not  move  the 
limb  :  it  seems  to  hang  paralysed  and  inert,  and  this 
appearance,  with  the  wasting  of  muscle  that  always 
supervenes,  has  given  to  the  condition  the  name  of 
syi)hilitic  pseudo-paralysis. 

In  the  teeth  the  condition  is  that  first  described  by 
and  named  after  Mr.  Jonathan  Hutchinson.  It  is  a 
pegging  and  notching  of  the  permanent  upper  central 
incisors.  The  teeth  are  too  small  for  the  spaces  they 
have  to  fill ;  they  tend  to  become  pointed,  then  cutting 
edges  are  hollowed  out  and  crescentic,  or  notched  and 
tuberculated.  The  lateral  incisors  are  sometimes 
pegged  also,  and  the  canines  are  often  too  pointed. 
The  cause  is  probably  an  old  stomatitis  interfering 
with  the  development  of  the  tooth  bulbs.  {See  Art.  on 
Syphilis.) 

Hypertrophic  chang^es  in  coiigfciiital  sy- 
philis are  met  with  as  localised  subperiosteal  develop- 
ments of  porous  bone  in  the  bones  of  the  skull  and  in 
some  of  the  long  bones. 

In  the  skull  they  are  known  as  Farrot^s  nodes  or  osteo- 
phytes. They  appear  as  broad  flattened  bosses,  usually 
four  in  number,  upon  the  four  bones  that  surround  the 


138  Manual  of  Surgery. 

anterior  fontanelle,  but  are  found  also  skirting  the  sagit- 
tal and  coronal  sutures.  Tliey  are  composed  of  spongy 
vascular  bone  with  wide  spaces.  Such  growths  may 
attain  to  considerable  thickness,  as  much  as  half  an 
inch  ;  and  they  may  extend  laterally  so  as  to  cause 
prematui^e  closure  of  the  sutures.  They  very  rarely 
break  down  and  suppurate.  They  nearly  always 
appear  between  the  sixth  and  the  twelfth  months. 

Ill  the  long  hones  such  nodes  are  usually  found  on 
the  tibia  or  the  humerus,  appearing  at  about  the  same 
ajje  and  followino-  the  same  course.  Their  site  is  near 
tlie  epiphyses,  and  most  frequently  in  the  neighbour- 
hood of  the  knee  and  elbow  joints. 

The  treatment  of  the  osseous  lesions  of  congenital 
syphilis  is  simply  that  of  the  constitutional  disease. 
Local  measures  are  not  called  for. 

Mollities  ossiiim ;  osteo-malaeia ;  iiiala- 
costcon,  -  This  is  a  constitutional  disease  charac- 
terised by  a  general  softening  of  the  osseous  tissue, 
rendering  it  liable  to  be  bent  or  broken. 

Causation.  —  Almost  nothing  is  known  of  the 
origin  of  this  rare  and  extraordinary  disease.  In  some 
few  cases  it  is  inherited.  It  is  twelve  times  more 
frequent  in  females  than  in  males,  and  among  females 
more  than  two-thirds  of  the  cases  appear  during  the 
child-bearing  period.  Most  usually  it  occurs  during 
and  after  adult  life  ;  but  it  has  been  met  with  at,  and 
even  before,  puberty.  Theories  as  to  its  being  caused 
by  a  dissolving  action  of  carbonic  acid  or  lactic  acid 
want  confirmation. 

Pathology. — The  essential  features  of  the  disease 
are,  replacement  of  the  medullary  tissue  by  a  dark-red 
grumous  semifluid  material,  and  rarefaction  and 
absorption  of  bone.  The  disease  advances  centrifu- 
gally,  beginning  usually  in  the  yellow  marrow,  and 
extending  upwards  and  downwards  into  the  red 
marrow  in  the  cancellous  bone,  and  outwards  into  the 


MOLLITIES  OSSIUM.  I  39 

compact  tissue.  Rarely,  however,  does  it  attack  the 
subperiosteal  outer  lamellae ;  in  the  most  advanced 
cases,  where  the  greater  part  of  the  bone  may  have  com- 
pletely disappeared,  there  nearly  always  remains  a 
thin  shell  of  comparatively  healthy  material  which 
maintains  the  shape  of  the  original  bone.  Into  the 
substance  of  this  pulpy,  vascular  material  haemorrhages 
frequently  take  place,  and  small  cystic  cavities  with 
fluid  contents  and  well-defined  walls  are  often  formed. 

The  salts  are  dissolved  out  as  if  by  an  acid,  leaving 
a  layer  or  zone  of  animal  substance,  which  in  its  turn 
is  broken  up  and  diftusod  in  the  new  growth. 

Symptoms.  —  In  the  early  stages  the  symptoms 
will  be  little  more  than  obscure,  shifting  pains  in  the 
bone  often  described  as  rheumatic.  No  other  sign  of 
disease  beyond,  perhaps,  general  malaise  and  ema- 
ciation, may  appear,  till  a  spontaneous  fracture  or 
bending  of  bone  takes  place.  An  examination  of  the 
urine,  revealing  the  presence  of  an  excess  of  phos- 
phates with  lactic  acid,  will  now  suggest  a  diagnosis, 
which  will  probably  soon  be  confirmed  by  the  occur- 
rence of  other  fractures  and  distortions.  On  the 
slightest  provocations  any  of  the  long  bones  may  bend 
or  break,  and  the  chest,  pelvis,  and  spine  may  be  dis- 
torted by  the  normal  pressure  they  have  to  bear.  In 
the  pelvis  the  deformity,  consisting  of  a  diminution  of 
the  oblique  diameters  from  pressure  inwards  by  the 
heads  of  the  femora,  is  a  frequent  cause  of  dithcult 
parturition,  occa.sionally  necessitating  operative  inter- 
ference. The  softened  ribs  may  permit  the  chest  to 
collapse,  and  the  patient  may  die  from  physical 
inability  to  breathe.  In  the  worst  cases  the  most 
extraordinary  appearances  may  be  produced  from  the 
exaggerated  distortions. 

A  few  cases  recover  ;  some  live  to  a  good  old  age 
while  the  disease  continues  ;  most,  however,  are  fatal. 

Treatment.  —  No   treatment    specially    aimed    at 


140  Manual  of  Surgekv. 

the  pathological  condition  has  been  found  of  the 
slightest  avail.  Treating  symptoms  we  may  give 
tonics  and  plenty  of  nourishment  to  maintain  the 
strength,  with  opium  to  relieve  pain  ;  while  to  prevent 
fractures  and  avoid  distortion  we  may  enjoin  rest  in 
the  recumbent  position. 

Tumours  of  Bone. 

Primary  malignant  growths ;  sarcoma.— 

Recent  investigations  seem  to  show  that  all  primary 
malignant  tumours  of  bone  belong  to  one  or  other  of 
the  varieties  of  sarcoma,  Scirrhus,  encephaloid,  and 
epithelioma  invade  bone  almost  never  except  as 
secondary  growths. 

Sarcomatous  tumours  in  bone  are  of  the  ordinary 
varieties,  i.e.  round-celled,  spindle-celled,  mixed,  and 
myeloid.  Bone  is  frequently  developed  in  their 
substance  (osteoid  sarcoma),  but  ossification  is  not 
confined  to  any  one  variety  of  growth.  The  best 
clinical  classification  is  into  central  and  peripheral 
sarcomata,  that  is  growths  arising  in  the  medulla  in 
the  centre  of  the  bone,  and  growths  arising  under  the 
periosteum. 

Central  sarcoma  of  bone  arises  usually  in 
the  cancellous  tissue  at  the  end  of  the  shaft.  As  it 
grows  it  pushes  the  compact  bone  in  front,  expanding 
and  thinning  it.  It  extends  along  the  medullary 
cavity  in  both  directions,  but  rarely  passes  the 
articular  cartilage  to  enter  the  joint.  The  thinned 
outer  shell  may  be  perforated  at  various  points,  and 
the  overlying  soft  tissues  are  then  invaded.  In  this 
state  spontaneous  fracture  is  liable  to  take  place.  All 
forms  of  sarcoma  are  met  with  in  the  centre  of  bones. 
Central  sarcomata  ossify  less  frequently  than  peri- 
pheral. They  may  attain  to  enormous  dimensions, 
and  are  peculiarly  liable  to  recur  in  internal  organs 


Sarcoma  of  Bone. 


141 


after  remo\  al.     Like  sareoaiata  elsewhere,  thej  rarely 
invade  the  lymphatics  (Fig.  29). 

Periplieral  or  subperiosteal  sarcoma  of 
boue  arises,  as  its  name  implies,  between  the  perios- 
teum and  the  bone. 
It  burrows  between 
these  tissues,  invad- 
ing the  bone  from 
the  outside.  Here 
also  all  varieties  of 
sarcoma,  are  met 
with.  Ossification 
is  more  common  in 
peripheral  than  in 
central  sarcoma.  In 
the  substance  of 
periosteal  sarcoma 
there  is  frequently 
developed  a  variety 
of  osteophyte,  com- 
posed of  spicules,  or 
closely-set  lamellse, 
or  hollow  tubes, 
which  are  probably 
developed  around 
the  periosteal  ves- 
sels, as  they  are 
draacijed  out  of  the 
underlying  bone  by 
the  growing  tu- 
rn ours.  Occa- 
sionally a  thrill  or  bruit  may  be  detected  in  the 
growth. 

Symptoms  and  diagnosis. — The  early  symptoms 
of  central  sarcoma  are  very  similar  to  those  of 
deep  osteitis,  namely,  deep-seated  pain  of  a  gnawing 
or  bursting  character,  with  some  tenderness.     When 


Fig.  29. — Myeloid  Sarcoma  of  Femur. 

«,  Cy~t  ;  b,  femur ;  c.  patella  :  d,  tibia  :  r,  fat ; 
/.  cartilage.  (From  Pepper's  "Surgical 
Pathology.") 


142  Manual  of  Surgery. 

swelling  comes  on,  the  rapidity  of  its  increase  with 
absence  of  redness  of  the  skin,  or  other  signs  of  inflam- 
mation, point  to  sarcoma.  When  the  growth  has 
attained  to  considerable  dimensions,  and  the  outer  shell 
of  bone  is  much  thinned,  manipulation  may  produce  a 
peculiar  sensation  of  crackling.  The  skin  stretched  over 
the  swelling  is  white  and  glossy,  with  blue  veins  cours- 
ing under  it.  Where  the  growth  has  escaped  from  its 
bony  shell,  the  soft,  boggy,  semifluctuating  nature  of 
the  tumour  may  be  detected.  Occasionally  there  is 
a  bruit  or  even  visible  pulsation. 

In  periosteal  sarcoma  there  is  less  pain.  The 
growth  feels  soft  and  boggy  from  the  beginning,  and 
in  the  early  stages  may  even  be  mistaken  for  abscess. 
By  deep  pressure  an  overlapping  margin  of  tumour 
substance  may  be  felt,  and  this,  with  its  firm  connec- 
tion with  the  underlying  bone,  will  help  to  distinguish 
it. 

In  both  central  and  peripheral  sarcoma,  a  history 
of  injury  is  curiously  frequent,  so  frequent,  indeed, 
that  traumatism  must  be  considered  as  predisposing, 
if  not  causal. 

It  is  possible  to  mistake  sarcoma  in  the  neighbour- 
hood of  a  joint  for  strumous  disease.  In  those  cases 
where  cartilage  is  found  in  a  sarcomatous  growth,  it 
is  sometimes  impossible  to  diagnose  it  from  enchon- 
droma.  Generally  speaking,  enchondroma  is  harder, 
and  more  tubercular  on  the  surface,  while  it  in- 
creases in  size  less  rapidly.  Clinically,  it  is  usually 
impossible  to  distinguish  the  histological  varieties  of 
sarcoma. 

I'reatment.  —  The  only  treatment  for  sarcoma 
in  l)one  is  to  remove  it.  Such  removal  must  nearly 
always  involve  amputation  of  the  limb.  In  periosteal 
sarcoma  it  may  be  possible  to  remove  the  growth,  and 
as  much  of  the  bone  as  may  be  imjjlicated,  but  very 
rarely  is  it  wise  to  be  content  with  this.     In  endosteal 


Sarcoma  of  Bone,  143 

growths  amputation  must  always  be  performed.  If 
the  growth  is  small  and  circumscribed,  it  may  be 
possible,  by  amputating  through  the  bone  above  the 
gro^vth,  to  remove  the  whole  of  the  disease.  But  in 
most  cases  it  will  be  wise  to  amputate  through  the 
joint  above  the  disease.  The  disease  extends  along 
the  medulla  with  such  rapidity  that  only  in  the  early 
stages  is  it  likely  to  be  unaffected,  and  thus  the 
greatest  security  against  recurrence  is  got  by  disarticu- 
lating the  bone.  When  the  intermuscular  fasci?e  are 
affected,  amputation  through  the  joint  is  still  more 
necessary. 

Myeloid  sarcoma  is  supposed  to  give  the  best 
results  after  amputation  through  the  bone  ;  spindle- 
celled  sarcoma  ought  always  to  be  treated  by  disar- 
ticulation. In  either  case  secondary  recurrence, 
especially  in  the  internal  organs,  and  particularly  in  the 
lungs,  takes  place  in  many  instances  after  operation. 

Secondary  lualigiiaut  g^'owtlis  in  bone* 
— All  secondary  malignant  diseases  in  bone  are  endos- 
teal, unless  they  are  direct  extensions  from  contiguous 
growths,  when  they  may  be  periosteal. 

Sarcoma  in  any  situation  may  produce  secondary 
disease  in  bone  by  infection  from  a  distance.  Carci- 
noma in  bone  is  practically  always  secondary,  most 
frequently  it  is  metastatic,  though  in  certain  situations, 
as  in  the  ribs  from  cancer  of  the  breast,  it  is  not 
uncommon  as  a  direct  extension  of  the  disease.  Ence- 
l)haloid,  as  secondary  to  disease  of  the  liver,  is  not 
uncommonly  found  in  bone.  Epithelioma  of  bone  is 
rare ;  it  always  originates  by  direct  invasion  from  the 
soft  tissues. 

Osteo  -  aneurism ;  pulsating:  g^rowths  of 
bone. — Midway  between  the  benign  and  tlie  malig- 
nant tumours  of  bone  is  the  class  clinically  known  as 
pulsating.  Of  such  there  are  at  least  three  distinct 
varieties. 


144  Manual  of  Surgery. 

1.  The  most  common  pulsating  growths  are  soft 
sarcomata,  in  which,  from  the  great  number  cf  largo 
vessels,  or  from  dilatations  in  their  walls,  a  general 
distension  of  the  mass  takes  place  at  each  beat  of  the 
heart.  Vascular  thrills,  or  even  perceptible  pulsations, 
are  not  infrequently  met  with  in  ordinary  myeloid  or 
spindle-celled  sarcomata  ;  the  variety  under  considera- 
tion is  merely  one  in  which  pulsation  is  an  abnormally 
prominent  feature. 

2.  As  a  second  variety  are  classed  certain  vascular 
erectile  tumours,  composed  of  numerous  interlacing 
small  vessels,  similar  to  ordinary  ntevus  of  the  soft 
tissues.  Such  are  usually  found  on  the  skull,  form- 
ing soft  reddish  elevations,  which  pulsate  under  the 
skin. 

3.  True  aneurism  of  bone,  though  in  many  cases 
it  has  been  confused  ^vitll  pulsating  sarcoma,  is  now 
generally  admitted  to  exist.  It  is  simply  a  cavity  in 
the  interior  of  bone,  containing  blood,  partly  fluid  and 
partly  clotted,  which  visibly  pulsates.  It  is  in  fact 
an  ordinary  aneurism,  which  happens  to  be  located  in 
the  interior  of  a  bone. 

Symptoms  and  diagnosis. — A  growth  in  the  sub- 
stance of  a  bone,  which  distends  it,  which  pulsates, 
and  which  perhaps  emits  a  bruit,  may  be  sarcoma,  or 
time  aneurism.  If  the  pulsation  is  distinctly  expansile, 
and  the  vascular  thrill  very  palpable,  and  the  bruit  is 
loud  and  well  marked,  we  may  suspect  tiiie  osteo- 
aneurism,  though  we  can  seldom  be  cei'tain.  Compres- 
sion of  the  main  artery  checks  the  pulsation  ;  if  it  is 
a  vascular  erectile  tumour  it  visibly  diminishes  in 
size ;  if  a  pulsating  sarcoma,  it  simply  becomes  less 
tense  ;  if  a  true  osteo-aneurism,  there  is  no  diminution 
in  bulk,  but  relief  of  tension  will  render  palpable 
certain  openings  in  the  expanded  bony  shell.  The 
last  is  exceedingly  rare,  and  unless  the  signs  are  very 
definite  indeed,  we  must  conclude  that  the  disease  is 


Osteoma.  145 

a  pulsating  sarcoma.  An  accurate  diagnosis  is  usually 
impossible. 

Treatment.  —  Deligation  of  the  main  artery  of 
the  limb  having  in  most  cases  been  performed  for 
pulsating  sarcoma  cannot  claim  many  successes. 

A  few  cases  of  cure  by  ligation  for  simple  osteo- 
aneurism  have  been  recorded.  In  vascular  erectile 
tumours  of  the  scalp,  or  scapula,  or  other  flat  bones, 
ligation  of  the  arteries  entering  them  may  produce 
cure.  In  pulsating  sarcoma,  amputation,  on  the  lines 
laid  down  for  ordinary  sarcoma,  is  the  only  resource. 

JVoM-naalig^iiaiit  gi'OAVths. —  These  are  either 
localised  over-growths  of  the  tissues  that  normally 
enter  into  the  formation  of  osseous  tissue  (cartilage, 
fibrous  tissue,  or  true  bone) ;  or  they  are  cystic  de- 
velopments, simple  or  parasitic. 

Osteoma;  exostosis. — With  very  few  excep- 
tions, all  bony  tumours  grow  outwards ;  the  few  that 
grow  inwards  are  probably  inflammatory.  Practically, 
therefore,  all  osteomata  are  exostoses ;  enostoses  may 
be  ignored.     They  are  of  three  sorts  : 

The  ivory  osteoma,  or  exostosis,  is  usually  found  on 
the  surface  of  the  skull,  frequently  on  its  cerebral 
aspect,  as  a  smooth,  hard,  rounded  growth,  composed 
of  exceedingly  dense  bone  of  a  consistence  resembling 
that  of  ivory.  Most  probably  it  is  a  true  periosteal 
growth.  The  bone  is  arranged  in  parallel  laminae ; 
the  bone  corpuscles  are  small  and  have  long,  slender 
processes  ;  and  the  blood-vessels  are  small  and  sparsely 
distributed.  As  it  gets  older  the  bone  increases  in 
density,  sometimes  to  such  an  extent  that  its  vascular 
supply  is  cut  off,  causing  a  quiet  necrosis  and  separation, 
as  in  the  stain's  horn. 

The  spongy  osteoma,  or  exostosis,  is  found  arising 

either    from   the    neighbourhood  of    the   epiphysis  of 

a  long  bone,  or  from  the  flbro-cartilaginous  insertion 

of  some  large  mass  of   muscle.      It  is  developed  in 

K-21 


146 


Manual  of  Surgery. 


Pig.  30.— Transverse  Section  of  a  Simple 
Cancellous  Exostosis,  originating  in  tlie 
Linea  Aspera  of  the  Femur.  There  is  no 
change  in  the  structure  of  the  Femur. 
(Museum,  Bristol  Koyal  Infirmary.) 


cartilage,  and  is  areolar  or  spongy,  and  not  laminated, 
except  on  the  surface.  Usually  it  appears  before 
puberty,  and  it  may  go  on  growing  for  an  indefinite 
period.  Its  structure  is  that  of  ordinary  cancellous 
bone.     A  layer  of  cartilage  usually  overlies  the  spongy 

osteoma,  and  in  it 
may  be  found  the 
microscopic  appear- 
ances of  ordinary 
intracartil  a  g  i  n  o  u  s 
development  of 
bone  (Fig.  30). 

Hereditary  mul- 
tiple osteoinata  occur 
in  children,  and 
may  affect  most 
of  the  bones  of  the 
body.  As  the  name  implies,  the  disease  is  usually 
inherited.  The  tumours  appear  as  hard,  nodulated 
growths,  situated  mostly  near  the  ends  of  the  long 
bones,  though  they  are  found  on  other  situations. 
They  may  be  very  numerous,  and  may  go  on 
increasing  in  number  and  in  size  for  years,  causing  no 
harm,  except  through  interference  with  movement  of 
the  joints.  They  are  covered  with  cartilage,  and  are 
of  the  nature  of  spongy  exostoses.  The  disease  is 
veiy  rare. 

Symptoms  and  diagnosis.  —  Unless  it  inter- 
feres with  neighbouring  tissues  or  organs,  the  signs  of 
osteoma  are  purely  physical.  A  hard,  rounded,  or 
iiTegular  tumour  firmly  attached  to  bone,  painless, 
and  non-inflammatory,  and  with  a  history  of  very 
slow  growth,  are  its  leading  characteristics.  The 
situation  of  the  ivory  osteoma  on  the  skull,  its  smooth 
rounded  sui-face  and  small  size,  are  diagnostic.  The 
most  common  situation  of  the  s])ongy  osteoma  is  on 
the  linea  aspera  of  the  femur  (Fig.  30);  it  is  found 


Enchondrohia.  147 

also  on  the  supracondyloid  ridges  of  the  humerus, 
and  on  the  inner  side  may  be  confounded  with  a 
supracondyloid  process.  It  is  found  also  under  the 
nail  of  the  great  toe  (ungual  exostosis),  elevating  the 
nail  and  causing  much  pain  and  inconvenience  by 
pressure  from  boots. 

Exostosis  is  most  readily  confounded  with 
enchondroma  of  bone,  and  particularly  with  ossifying 
enchondroma.  The  latter  grows  more  rapidly,  and  is 
more  irregular  on  the  surface  than  the  former. 

Treatment. — Unless  it  disturbs  the  function  of 
neighbouring  organs  or  produces  some  conspicuous 
deformity,  an  osteoma  need  not  be  interfered  with. 
Situated  close  to  important  structures,  as  in  the  orbit, 
or  on  the  inside  of  the  skull,  or  near  a  joint,  its  re- 
moval is  attended  with  some  difficulty  and  risk.  The 
growth  is  taken  away  by  means  of  saw,  chisel,  gouge, 
or  bone  forceps.  It  has  been  found  that  unless  re- 
moval is  complete  and  thorough,  recurrence  sometimes 
takes  place. 

Eiichondronia.— This  is  the  most  common  of 
innocent  tumours  of  bone.  It  is  met  with  most 
frequently  near  the  extremities  of  the  long  bones, 
and  no  doubt  originates  in  many  cases  from  the 
epiphysial  cartilage.  It  is  found  either  as  a  diffuse 
growth  infiltrating  the  whole  bony  structure,  or  as  a 
circumscribed  outgrowth  from  the  compact  shell. 
The  former  is  most  common  in  the  larger  bones,  the 
latter,  often  multiple,  in  the  long  bones  of  the  hands 
and  feet.  Centres  of  ossification,  or,  more  accurately, 
of  calcification,  are  met  with  most  frequently  in  the 
circumscribed  enchondroma,  and  sometimes  tliese  are 
so  thickly  set  as  to  constitute  calcification  of  the 
whole  mass.  All  the  ordinary  pathological  changes 
found  in  enchontlroma  generally  are  met  with  in 
enchondroma  of  bone.  The  tumours  are  usually 
slow  in  growth,  but    sometimes    they   increase  with 


148  Manual  of  Surgery. 

great  rapidity,  and  may  attain  to  enormous  dimen- 
sions. 

jSymptoyns  and  cliaynosis.  —  A  painless  or  but 
sliglitly  painful  hard  or  semielastic  tumour  of 
slow  growth,  attaclied  to  bone,  nodulated  on  the 
surface,  not  invading  the  skin,  and  presenting  none  of 
the  characters  of  malignancy,  is  probably  an  enchon- 
droma.  A  thin  shell  of  periosteal  bone  sometimes 
surrounds  it,  when  characteristic  crackling  on  manipu- 
lation may  be  detected.  If  small  and  calcified  it  may 
be  indistinguishable  from  a  pure  osteoma,  though  the 
irregular  bosses  on  its  surface  are  usually  distinctive. 

Treatment. —  In  the  circumscribed  variety,  com- 
plete removal  of  the  growth,  with  gouging  of  the 
bony  surface  from  which  it  springs,  will  probably 
effect  a  cure.  If  the  growth  is  central,  extending  up 
the  medullary  canal,  the  limb  must  be  amputated 
above  the  disease.  Generally  speaking,  removal  of 
the  growth  will  cure  in  enchondroma  of  the  bones 
of  the  hands  and  feet ;  in  enchondroma  of  the  long 
bones  amputation  of  the  limb  will  be  called  for. 

Fibrous  and  fibro-cystic  g^rowtlis. — As 
originating  from  the  gums  (epulis)  or  from  the  perios- 
teum covering  the  bones  in  the  nasal  cavities  (fibrous 
polypus),  fibrous  tumours  of  bone,  or  rather  of 
periosteum,  are  not  uncommon.  Elsewhere  they  are 
almost  unknown.  Instances  of  fibro-cystic  growths, 
mostly  in  the  femur,  have  been  recorded,  but  they  are 
so  rare  as  to  be  clinical  curiosities. 

Cysts  ill  boiie. — With  the  exception  of  denti- 
gerous  cysts,  simple  cysts  in  bone  are  extremely 
rare.  Most  of  those  described  as  sanguineous  cysts 
were  probably  sarcomata.  Hydatid  cysts  may  be  found 
in  bone  as  in  every  other  tissue,  but  their  occuiTenoe, 
particularly  in  England,  is  very  uncommon. 


149 


III.     INJURIES    OF  JOINTS. 

T.  Pickering  Pick. 

Contusions.  —  Joints  are  often  contused  by 
direct  violence,  siicli  as  falls,  blows,  or  kicks.  The 
injury  ought  always,  but  especiall}"  in  the  young  and 
delicate,  to  be  regarded  as  of  a  serious  nature ;  for 
with  very  slight  external  evidence  of  injury  a  very 
considerable  amount  of  mischief  may  be  set  up,  or 
consecutive  inflammation  of  the  structures  entering 
into  the  formation  of  the  joint  may  follow  and  involve 
the  integrity  of  the  articulation.  Thus,  in  delicate 
children,  a  contusion  of  the  hip,  from  a  fall  on  the 
trochanter,  may  be  the  starting  point  of  hip  joint 
disease,  which  may  run  its  course  to  complete  destruc- 
tion of  the  articulation. 

In  some  cases  there  is  little  to  mark  the  injury 
beyond  the  history  of  the  accident  and  pain,  increased 
on  moving  the  joint ;  in  other  cases,  rapid  swelling 
of  the  articulation  follows,  indicating  the  effusion  of 
blood,  mixed  w^th  synovia^  into  the  cavity  of  the  joint. 
In  these  latter  the  blood  and  fluid,  under  the  in- 
fluence of  appropriate  treatment,  is  slowly  absorbed, 
generally  without  leading  to  any  permanent  incon- 
venience. 

Treatment. — The  essence  of  the  treatment  consists 
in  perfect  rest  and  the  maintenance  of  complete  im- 
mobility of  the  joint  by  the  application  of  a  splint ; 
and  there  is  good  rea-son  to  believe  that  in  the 
majority  of  cases,  if  this  treatment  were  thoroughly 
carried  out,  no  untoward  results  would  ensue.  The 
limb  should  be  raised,  and  cold,  by  means  of  evaporat- 
ing lotions,  Leiter's  tubes,  or  an  ice  bag  assiduously 


150  Manual  of  Surgery. 

applied.  If  the  joiut  is  so  much  distended  with 
fluid  as  to  cause  tension  and  severe  pain,  it  may  be 
relieved  by  means  of  the  aspirator. 

Spi'niiis. — By  the  term  "sprain"  we  mean  a 
violent  twisting  or  wrenching  of  a  joint,  whereby  its 
liofamentous  and  tendinous  structures  are  stretched  or 
torn,  but  *in  which  there  is  no  separation  or  displace- 
ment of  the  bony  surfaces  from  each  other. 

The  amount  of  lesion  which  takes-  place  varies 
very  much  in  different  cases,  from  a  slight  tearing  of 
a  few  ligamentous  fibres  to  a  complete  laceration  or 
detachment  of  one  or  more  of  the  ligaments  of  the 
joint,  with  perhaps  displacement  of  tendons  from  their 
sheaths,  laceration  of  muscles  or  tendons,  and  con- 
siderable extravasation  of  blood.  In  some  cases  small 
scales  of  bone,  to  which  the  ligaments  are  attached, 
may  be  torn  away,  constituting  the  "  sprain  fractures  " 
described  by  the  late  Mr.  Callender.  The  lesions, 
therefore,  of  a  severe  sprain  closely  resemble,  and 
differ  only  in  degree  from,  those  of  fracture,  with 
which  they  are  very  liable  to  be  mistaken. 

Symptoms. — The  immediate  effect  of  a  sprain  is 
very  severe  pain,  often  of  a  sickening  character. 
This  is  rapidly  followed  by  a  swelling,  partly  due  to 
extravasation  of  blood  into  the  surrounding  tissues, 
and  partly  to  effusion  taking  place  into  the  cavity  of 
the  joint,  as  the  result  of  inflammation  which  has 
been  set  up  by  the  injury.  After  a  short  time,  dis- 
coloration, extending  for  some  distance  above  and 
below  the  joint,  makes  its  appearance.  There  is,  of 
course,  inability  to  bear  any  weight  on  the  limb,  and 
any  attempt  to  move  the  joint  surfaces  on  each  other 
is  attended  by  increased  pain.  The  degree  and  extent 
of  these  symptoms  depend  upon  the  amount  of  injury 
which  has  been  sustained. 

The  remote  effects  of  this  lesion  are  often  per- 
manent  pain   and  weakness ;   or  stiffness   and   even 


Sprains  of  Joints.  1 5 1 

anchylosis.  The  former  of  these  conditions  may  arise 
from  imperfect  repair  of  the  torn  structures,  or  from 
non-absorption  of  the  effused  fluid  ;  the  latter  from 
chronic  inflammation  causing  adhesions  within  the  joint, 
or  in  the  sheaths  of  the  neighbouring  tendons.  In  some 
constitutional  conditions,  as  the  rheumatic  or  scrofu- 
lous, the  subsequent  inflammation  may  assume  the 
characteristic  type  of  these  conditions,  and  may  be 
very  persistent. 

Treatment.  —  The  treatment  of  sprains  requires 
as  much  care  and  attention  as  the  treatment  of  many 
graver  injuries,  and  perhaps  even  a  greater  amount 
of  judgment  on  the  part  of  the  surgeon  ;  for  whereas 
rest  is  absolutely  necessary  for  the  repair  of  the 
lacerated  tissues,  too  protracted  rest  is  often  mis- 
chievous, stiffening  the  joint  and  delaying  recovery, 
so  that  it  often  requires  great  discrimination  on  the 
part  of  the  surgeon  to  know  how  long  to  continue 
to  keep  the  joint  at  rest  and  when  to  commence 
passive  motion.  Immediately  after  the  receipt  of  the 
injury  the  limb  should  be  laid  on  a  pillow  in  the 
position  most  comfortable  to  the  patient,  or,  what  is 
perhaps  better,  loosely  connected  to  a  splint,  taking 
care  to  leave  the  injured  part  exposed.  This  plan 
secures  perfect  immobility  of  the  joint,  and  at  the 
same  time  prevents  stretching  of  the  damaged  tissues 
by  supporting  the  limb.  Cold  assiduously  applied, 
with  a  view  to  subdue  inflammation  and  prevent 
further  eflusion,  will  generally  be  found  most  agree- 
able to  the  patient.  This  may  best  be  done  by 
ii'rigation  with  spirits  and  water,  which  is  to  be 
preferred  to  the  application  of  a  bag  of  pounded  ice, 
or  Leiter's  tubes,  the  weio^ht  of  which  is  fjenerallv  a 
source  of  annoyance  and  discomfort.  Sometimes  warm 
applications,  such  as  hot  Goulard  water  with  lauda- 
num, or  poppy  fom-entations,  are  more  grateful  to  the 
patient,  and  may  be  then  applied.     As  soon  as  the 


152  Manual  of  Surgery. 

patient  can  bear  it,  equable  pressure  must  be  re- 
sorted to  and  will  be  found  to  be  a  most  ])otent 
means  of  promoting  absorption  of  the  effused  fluids. 
This  can  be  done  by  means  of  a  bandage  wetted  in  lead 
lotion  and  carefully  applied,  the  bandage  being  kept 
constantly  damp  with  the  lotion  ;  or  strapping  may 
be  used.  This  treatment  must  not,  however,  be  con- 
tinued too  long,  but  as  soon  as  the  patient  can  bear 
passive  motion  without  pain  or  renewed  inflammation, 
systematic  shampooing  and  movement  of  the  joint 
must  be  resorted  to,  with  friction,  and  the  patient 
must  be  encouraged  to  use  the  limb  as  much  aa 
possible  without  causing  himself  pain. 

'Woitiids  of  joints. — These  are  always  serious 
accidents,  the  severity  depending  partly  upon  the 
nature  of  the  wound  and  the  size  of  the  articulation,  but 
also,  to  a  considerable  extent,  upon  the  age  and  general 
constitutional  condition  of  the  patient.  The  wound  may 
be  incised,  punctured,  or  lacerated ;  but  the  severity  of 
the  symptoms  does  not  depend  so  much  upon  the 
extent  or  nature  of  the  local  mischief,  as  upon  the 
fact  that  putrescible  matter  collects  in  the  cavity  of 
the  joint  and  undergoes  decomposition,  setting  up  a 
serious  train  of  symptoms  and  leading  to  complete 
destruction  of  the  articulation.  Medium-sized  wounds 
are  often,  therefore,  the  most  dangerous,  especially  if 
the  edges  are  contused  and  lacerated,  so  that  they 
cannot  unite  by  adhesive  inflammation  and  at  the 
same  time  are  not  large  enough  to  permit  of  the 
thorough  drainage  from  the  cavity  of  the  effused 
fluids. 

If  the  wound  into  the  joint  is  large,  so  that 
the  articular  surfaces  are  exposed,  the  nature  of 
the  injury  is  at  once  evident ;  but  if  the  wound 
is  small,  and  particularly  if  it  belongs  to  the  class 
of  punctured  wounds,  some  doubt  may  arise  as  to 
whether  the  joint   has   been    opened   or    not     Tliia 


Wounds  of  Joints.  153 

will  generally  be  solved  by  the  escape  of  synovia^ 
which  will  be  at  once  recognised  by  its  oily  glu- 
tinous character.  In  some  cases,  however,  this  fluid 
does  not  exude ;  but  under  no  circumstances  is  it 
admissible  to  introduce  a  probe  to  clear  up  any  doubt 
in  the  surgeon's  mind,  for  it  may  have  the  effect  of 
completing  the  perforation  into  the  articular  cavity, 
and  thus  inducing  the  very  mischief  which  is  to  be 
dreaded.  The  standard  rule  in  every  case  of  wound 
in  the  neighbourhood  of  a  joint,  running  in  the  direc- 
tion of  the  articulation,  ought  to  be  to  treat  the  case 
as  one  of  ivoicnd  of  the  joint,  until  the  subsequent 
progress  of  the  case  proves  that  no  jDerforation  has 
taken  place,  or  that,  if  it  has,  the  wound  has  rapidly 
healed,  without  setting  up  a  serious  amount  of 
inflammation. 

Pathology. — When  a  joint  is  wounded  it  rapidly 
becomes  filled  with  an  accumulation  of  blood,  folloAved 
almost  immediately  by  synovial  fluid,  mixed  with 
serum  derived  from  the  vessels  of  the  synovial  mem- 
brane and  the  clotted  blood  in  the  sac.  Thus  the  joint 
is  distended  with  a  highly  putrescible  matter,  to  which 
air  is  admitted  through  the  Avound.  It  therefore 
rapidly  undergoes  decomposition,  and  becomes  con- 
verted into  a  septic  material,  which  results  in  an  acute 
inflammation  of  all  the  tissues  of  the  joint. 

Thei'e  are  certain  cases  where  this  may  not  occur, 
even  though  no  special  treatment  is  adopted  to  pre- 
vent it.  If,  for  instance,  the  wound  is  small,  and  is 
inflicted  with  a  clean  instrument,  and  if  the  edges  are 
brought  into  immediate  apposition,  union  by  adhesive 
inflammation  may  take  place  ;  no  air  is  admitted  to 
the  joint,  and  no  decomposition  of  the  eflused  fluids 
ensues.  Thus,  we  find  that  a  surgical  wound  may  be 
made  into  a  joint,  as,  for  instance,  for  the  removal  of 
a  loose  cartilage,  without  any  destructive  changes 
taking  place  in  the  joint.       Again,  on  the  other  hand, 


154  Manual  of  Surgery, 

if  the  wound  is  large  and  the  articulation  freely 
opened,  so  as  to  allow  the  effused  fluids  to  escape,  no 
retention  of  decomposable  matter  takes  place,  and 
there  is  therefore  no  septic  influence  brought  to  bear 
on  the  part,  and  recovery  may  take  place  without 
any  severe  local  or  constitutional  disturbance. 

If,  however,  the  cavity  becomes  filled  witli 
putrescible  material,  decomposition  speedily  sets  in,  if 
this  material  is  brought  into  contact  with  impure  air ; 
and  acute  inflammation  running  on  to  suppuration  is 
the  result.  During  the  first  twenty-four  hours  or  so, 
the  synovial  membrane  becomes  intensely  injected  and 
red,  and  loses  its  natural  lustre.  Its  fringes  also 
become  injected  and  swollen.  The  cavity  becomes 
filled  with  a  thin,  turbid  synovia,  in  which  bacteria 
are  commonly  to  be  found  on  microscopic  examina- 
tion. The  ligaments  become  swollen  and  softened. 
The  cartilages  lose  their  natural  lustrous  appearance, 
and  become  opaque  and  yellow,  loosened  from  the 
surface  of  the  bone,  and  eventually  they  perish  and 
become  eroded,  especially  in  their  centres,  or  where 
the  two  articular  surfaces  are  in  contact.  Tho 
articular  ends  of  the  bones  become  exposed  and 
superficially  ulcerated.  The  inflammation  extends  to 
the  structures  outside  the  joint,  which  become 
(edematous,  and  in  which  suppuration  occurs.  Later 
on,  in  about  a  week  or  ten  days,  the  joint  surfaces 
become  covered  with  a  layer  of  granulation  tissue,  and 
the  cavity  of  the  joint  filled  with  a  thick  creamy  pus. 
It  is  now  impossible  to  recognise  the  various  structures, 
which  present  a  uniform  gelatinous  appearance, 
infiltrated  with  inflammatory  products.  In  this  way, 
the  whole  of  the  tissues  of  the  joint  are  thoroughly 
disorganised  and  destroyed,  and  the  bone  surfaces  laid 
bare  and  ulcerated. 

If  the  patient's  strength  has  survived  this  pro- 
tracted disintegration,  a  reparative  process  now  sets  in. 


IVOUNDS   OF  JOINTS.  155 

Granulations  spring  up  from  the  exposed  bony 
surfaces,  and,  coalescing,  become  converted  into  osseous 
matter,  just  in  the  same  manner  as  in  the  union  of 
a  compound  fracture,  and  complete  synostosis  takes 
place. 

SjTiiptonis. — If,  in  a  case  of  wound  of  a  joint, 
these  untoward  conditions  are  set  up  and  the  case 
becomes  one  of  septic  inflammation,  within  a  few 
hours  of  the  receipt  of  the  injury  great  swelling  of 
the  joint  comes  on,  accompanied  by  acute  lancinating 
paiiL  The  swelling  is  at  first  eWdently  due  to 
effusion  into  the  synovial  membrane,  and  takes  the 
shape  of  this  sac ;  but  after  a  time  the  tissues 
external  to  the  joint  become  infiltrated,  and  the 
swelling  more  globular.  The  skin  is  red,  hot,  and 
oedematous.  The  pain  rapidly  increases  and  becomes 
tensive  in  character.  If  the  wound  is  left  open, 
synovia,  turbid  and  opaque  and  mixed  with  shreds  of 
lymph,  escape.  The  limb  is  semiflexed.  Later  on 
the  pain  becomes  altered  in  character,  and  is  de- 
scribed as  throbbin£f.  The  swellingf  and  cedema 
around  the  joint  increase,  and  the  redness  is  of  a 
more  dusky  hue.  There  is  starting  of  the  limb, 
especially  at  night,  or  as  soon  as  the  patient  fiills 
asleep.  The  constitutional  symptoms  are  very  severe, 
especially  during  the  first  ten  days  or  so,  during 
which  time  absorption  readily  takes  place  through 
the  synovial  membrane.  Later  on,  when  this  struc- 
ture becomes  covered  with  granulation  tissue  which 
oflers  a  barrier  to  septic  absorption,  the  fever  often 
becomes  considerably  lessened.  In  the  early  stages 
the  temperature  is  very  high,  the  thermometer 
sometimes  registering  105°  or  106^  Tlie  pulse  is  full 
and  bounding ;  the  skin  hot  and  dry ;  the  face 
flushed,  and  the  tongue  covered  with  a  thick  creamy 
fur.  There  is  often  nocturnal  delirium,  with  restless- 
ness and  inability  to  sleep.     Or  should  the  patient 


156  Manual  of  Surgery. 

fall  asleep,  he  will  be  awakened  by  the  sudden, 
painful  starting  of  his  limb.  Later  on,  when  the 
fever  lessens,  it  assumes  a  more  hectic  type.  There 
are  often  rigors,  and  the  patient  may  die  from 
pyaemia,  or,  at  a  still  later  period,  from  exhaustion 
from  the  excessive  discharge. 

If  the  wound  in  the  joint  is  small,  and  unites  by 
first  intention,  and  the  patient  escapes  the  danger  of 
septic  inflammation,  there  will  probably  be  some 
swelling,  from  eflusion  into  the  joint,  accompanied  by 
heat  and  j)ain,  which  will  pass  off  in  the  course  of  a 
few  days,  and  the  joint  be  completely  restored,  though 
it  may  be  stiff  and  tender  for  some  time. 

Treatment. — The  first  question  which  presents 
itself  in  considering  the  treatment  of  a  case  of  wound 
of  a  joint  is  as  to  whether  any  operative  interference 
will  be  necessary  or  not.  And  in  deciding  this  question 
much  will  depend  upon  the  joint  implicated,  its  size, 
and  whether  it  is  situated  in  the  upper  or  the  lower 
extremity.  Wounds  of  the  joints  of  the  upper  limb, 
as  a  rule,  do  much  better  than  those  of  the  lower.  To 
this,  however,  there  are  exceptions,  for  wounds  of  the 
wrist  joint  are  particularly  dangerous,  while  those  of 
the  ankle,  unless  complicated  witli  fracture,  or  exten- 
sive injury  to  the  soft  parts,  often  do  well,  and  recovery 
takes  place  with  a  fairly  useful  limb.  If  the  joint  has 
been  extensively  opened,  with  much  contusion  and 
laceration  of  the  edges  of  the  wound,  and  especially  if 
the  articular  ends  of  the  bones  are  fractured  or  dis- 
placed, operative  measures  will  probably  be  necessary. 
In  less  severe  injuries  an  attempt  should  be  made  to 
save  the  joint.  Under  these  circumstances,  in  con- 
ducting the  treatment .  much  will  depend  ujwn  the 
nature  of  the  wound.  If  it  is  a  small  puncture  or  a 
cleanly  incised  wound,  especially  if  it  passes  obliquely 
into  the  joint,  an  endeavour  should  be  made  to  procure 
union  by  the  first  intention.    The  wound,  if  sufficiently 


Wounds  of  Joints.  157 

largo  to  require  it,  should  be  sewn  up  with  silver 
wire,  and  coated  with  collodion  or  some  other  material, 
which  will  completely  exclude  the  air.  The  limb  must 
be  placed  on  a  splint,  so  as  to  secure  perfect  immobility 
of  the  joint,  and  irrigation  with  cold  water,  or  spirit 
and  water,  assiduously  applied.  This  is  much  to  be 
preferred  to  the  application  of  an  ice  bag,  the  weight 
of  which  is  often  uncomfortable  and  distressing  to  the 
patient.  If  the  joint  swells  the  case  is  one  of  con- 
siderable anxiety  to  the  surgeon ;  but  as  long  as  the 
temperature  does  not  rise  to  any  considerable  extent, 
the  treatment  must  not  be  abandoned.  If  the  pain  is 
very  severe,  and  tensive  from  the  distension  of  the 
cavity,  the  fluid  should  be  evacuated  with  the  aspirator, 
and  opium  should  be  given  to  relieve  pain  and  pro- 
cure sleep.  If,  however,  the  temperature  rises,  and 
suppuration  has  evidently  taken  place,  long  and  free 
incisions  must  be  made  into  the  joint,  which  must  be 
thoroughly  washed  out  with  some  antiseptic  lotion,  such 
as  carbolic  acid  lotion  or  tincture  of  iodine  and  water, 
and  free  drainage  must  be  provided  for.  The  syiinging 
out  of  the  wound  must  be  continued  daily,  and  the  part 
must  be  dressed  with  carbolic  gauze,  carbolic  oil, 
boracic  acid,  lint,  salicylic  wool,  or  some  such  anti- 
septic material.  If  the  temperature  falls,  and  the  dis- 
charge lessens,  care  must  be  taken  to  maintain  the 
joint  in  such  a  position  that,  when  anchylosis  results, 
the  patient's  limb  shall  be  of  service  to  him.  If,  on  the 
other  hand,  the  high  temperature  is  maintained,  and 
the  discharge  continues  profuse,  and  symptoms  of  hectic 
develop,  amputation  must  be  at  once  resorted  to. 

If  the  wound  in  the  joint  is  a  large  one,  and  par- 
ticularly if  its  edges  are  contused  and  lacerated  so  as  to 
preclude  all  hope  of  obtaining  union  by  first  intention, 
the  case  must  be  treated  on  antiseptic  principles  from 
the  first,  so  as  to  endeavour  to  prevent  decomposi- 
tion.   The  joint  should  be  thoroughly  washed  out  with 


158  Manual  of  Surgery. 

caroolic  acid  lotion  (1  in  20),  and  every  particle  of 
foreign  matter  and  blood  clot  carefully  syringed  away. 
A  drainage  tube  is  to  be  inserted,  and  if  the 
wound  is  in  such  a  position  that  complete  drainage 
cannot  be  obtained,  a  counter- opening  is  to  be  made 
in  the  most  dependent  part,  and  a  tube  inserted.  The 
external  wound  must  now  be  closed  by  sutures,  and  the 
limb  fixed  on  a  splint  and  dressed  with  some  antiseptic 
dressing.  If,  in  spite  of  all  the  efforts  of  the  surgeon, 
septic  inflammation  should  supervene,  the  case  must 
be  treated  in  the  manner  before  mentioned.  Generally, 
however,  it  will  be  found  in  these  cases,  if  antiseptic 
measures  are  rigidly  carried  out,  that  though  sui> 
puration  may  come  on,  the  discharge  will  be  very 
slight  in  amount,  and  will  be  unaccompanied  by  fever, 
and  that  recovery  will  take  place  with  comparatively 
little  local  inflammation  or  constitutional  disturbance 
by  complete  bony  union  of  the  articular  ends. 

Dislocation. 

The  articular  surfaces  of  a  joint  may  become 
displaced  from  each  other,  either  as  the  result  of 
some  injury,  constituting  the  traumatic  form  of  dis- 
location ;  or  from  certain  destructive  changes  taking 
place  in  the  joint  and  surrounding  tissues,  so  that  the 
bony  surfaces  can  no  longer  be  retained  in  apposition, 
but  are  displaced  in  consequence  of  muscular  con- 
traction, or  the  weight  of  limb  or  trunk  (the  patho- 
logical form  of  dislocation) ;  or  lastly,  from  some  con- 
genital defect  or  malformation  of  the  joint,  in  con- 
sequence of  which  the  bones  cannot  remain  in  proper 
apposition  (the  congenital  form  of  dislocation). 

A  dislocation  may  be  either  partial  or  complete ; 
partial^  when  the  articular  surfaces  are  displaced  as 
regards  their  normal  relation  to  each  other,  but  are 
not  completely  separated,  so  that  some  portion  of  the 
articular  surface  of  one  bone  is  still  in  contact  with 


Causes  of  Dislocation.  159 

some  portion  of  the  articular  surface  of  the  other ; 
comjylete,  when  there  is  an  entii-e  separation  of  the 
two  articular  surfaces  from  each  other.  Dislocations 
may  be  either  simple  or  compound.  In  the  former 
the  integument  remains  unbroken,  while  in  the  latter 
the  displaced  articular  surfaces  are  exposed  by  a 
wound,  and  thus  air  is  admitted  into  the  ca-vity  of  the 
joint.  A  compound  dislocation  is  one  of  the  most 
serious  accidents  which  can  befall  a  limb.  It  is 
generally  complicated  with  other  injuries,  and  the 
lesion  is  usually  attended  with  the  most  severe  form 
of  injflammation,  which  rapidly  runs  on  to  suppuration 
and  complete  destruction  of  the  joint,  so  that  bony 
anchylosis  is  the  most  favourable  result  which  can 
ensue.  If,  however,  the  joint  is  small,  as  one  of  the 
phalangeal  articulations,  the  injury  may  be  recovered 
from  without  destruction  or  loss  of  motion. 

Causes. — The  causes  of  dislocation  have  to  be 
considered  under  two  heads,  viz.  (1)  predisposing,  (2) 
exciting  causes.  Among  the  predisposing  causes  may 
be  classed 

1.  Tlie  ■  nature  of  the  joint.  Ball-and-socket 
joints,  on  account  of  the  greater  freedom  of  motion 
which  they  enjoy,  are  much  more  liable  to  become 
dislocated  than,  for  instance,  a  hinge  joint,  where  the 
amount  of  movement  is  much  more  limited.  So  that 
it  may  be  laid  down  as  a  rule  that  the  greater 
freedom  of  motion  there  is  in  a  joint,  the  greater 
liability  there  will  be  to  dislocation.  2.  The  situa- 
tion of  the  joint.  Some  joints  are  much  more 
exposed  to  violence  than  others,  and  therefore  more 
frequently  dislocated.  3.  The  age  of  the  patient. 
Dislocations  generally  occiu'  in  adults  or  middle-aged 
individuals ;  being  rare  in  children  (with  the  ex- 
ception of  those  of  the  elbow  joint)  and  in  old 
people.  4.  The  sex  of  the  patient.  Males  are  much 
more  liable  to  suffer  from  dislocation  than  females,  on 


i6o  Manual  of  Surgery. 

account  of  tlieii'  greater  exposure  to  serious  injuries. 
5.  The  condition  of  the  structures  round  a  joint  may 
predispose  to  dislocation ;  for  example,  where  they 
Lave  been  stretched  by  previous  injury  or  effusion. 

The  exciting  causes  of  dislocation  are  two-fold  ; 
either  external  violence  or  muscular  action.  Violence 
may  cause  dislocation  in  two  ways,  either  directly,  froni 
blow  on  one  bone  entering  into  the  formation  of  a 
joint  driving  it  directly  away  from  the  other ;  or 
indirectly,  where  a  fall  or  blow  on  one  part  of  the 
bone  is  transmitted  to  its  extremity,  and  forces  it 
away  from  the  articular  surface  with  which  it  is  in 
contact. 

Symptoms. — The  signs  by  which  a  dislocation 
may  be  recognised  are  :  (1)  pain,  which  is  usually  of  a 
severe  and  sickening  character  ;  (2)  impaired  mobility, 
so  that  the  patient,  to  a  great  extent,  is  unable  to 
perform  the  various  voluntary  movements  of  the 
joint ;  (3)  change  in  the  shape  of  the  joint ;  (4) 
alteration  in  the  relation  of  the  bony  prominences  in 
the  neighbourhood  of  the  joint  to  each  other ;  (5)  the 
displaced  bone  can  sometimes  be  felt  in  its  new 
situation ;  (6)  an  alteration  in  the  length  of  the  limb  ; 
it  being  sometimes  lengthened,  sometimes  shortened, 
according  to  the  position  of  the  head  of  the  bone  ; 
(7)  and  an  alteration  in  the  direction  of  the  axis  of 
tlie  bone. 

Dislocations  may  sometimes  be  mistaken  for 
fractures  ;  the  chief  points  of  distinction  are  the  im- 
paired mobility,  the  absence  of  crepitus,  and  the  fact 
that  when  the  deformity  is  reduced  it  does  not  as  a 
rule  recur ;  whereas,  in  fractures,  the  displacement  at 
once  recurs,  as  soon  as  the  extending  force  has  been 
removed. 

Complications. — A  dislocation  is  always  com- 
plicated with  injury  to  the  structures  entering  into 
the  formation  of,  or  in  the  immediate  neighbourhood 


Treatment  of  Dislocations.  i6i 


of  the  joint.  The  bones,  ligaments,  muscleSj  vessels, 
and  nerves  may  all  suffer.  The  bones  are  very  fre- 
quently fractured  ;  in  fact,  in  some  joints,  notably  the 
ankle,  dislocation  rarely  occurs  without  fracture. 
The  injury  to  the  bone  may  vary  from  the  chipping 
off  of  some  small  fragment  to  the  extensive  comminu- 
tion of  the  articular  extremity  of  the  displaced  bone. 
Occasionally  fracture  of  the  shaft  of  a  bone  may  take 
place,  with  dislocation  of  its  extremity.  This  some- 
times occurs  in  the  humerus,  where  a  dislocation  of 
the  head  of  the  bone  is  complicated  with  fracture  of 
the  upper  part  of  the  shaft.  The  ligaments  which 
connect  the  bones  together  are^  as  a  rule,  more  or  less 
torn  in  all  complete  dislocations  ;  but  in  incomplete 
luxations  they  may  escape  laceration,  being  only 
severely  stretched.  The  muscles  which  surround  the 
joint  are  often  much  bruised  and  lacerated,  and 
tendons  in  the  neighbourhood,  especially  those  which 
are  connected  with  the  capsule,  are  sometimes  torn 
across.  Arteries  and  veins  in  the  vicinity  of  the 
joint  may  be  compressed  by  the  displaced  bone,  and 
all  circulation  through  them  arrested ;  or  they  may  be 
ruptured,  though  on  account  of  their  elasticity, 
especially  as  regards  the  arteries,  this  does  not  fre- 
quently take  place.  Kerves  in  the  neighbourhood 
may  be  lacerated,  contused,  or  compressed,  leading  to 
intense  pain  at  the  time  of  the  injury,  and  subsequently 
to  paralysis  of  the  muscles  they  supply. 

Treatment. — In  the  treatment  of  dislocations 
the  first  indication  is  to  endeavour  to  effect  reduction 
as  speedily  as  possible.  If  the  patient  is  seen  im- 
mediately after  the  accident,  he  will  probably  be  faint 
and  his  muscles  will  be  relaxed,  and  reduction  can  then 
be  easily  accomplished  unless  there  is  some  mechanical 
impediment.  If,  on  the  other  haud,  he  has  rallied  from 
the  first  shock  of  the  accident,  the  muscles  will  be  in 
a  condition  of  active  contraction,  and  will  offer  a 
L— 21 


i62  Manual  of  Surgery. 

considerable  impediment  to  reduction.  Under  these 
circumstances  it  is  wiser  to  administer  an  anaesthetic. 

There  are  two  principal  modes  of  reducing  dislo- 
cations, viz.  by  manipulation,  and  extension. 

Alanipulation  aims  at  reducing  a  dislocation  by 
making  the  bone  retrace  the  steps  by  which  it  has 
become  displaced.  This  is  done  by  executing  certain 
movements  of  the  limb,  which  shall  relax  the  liga- 
ments and  disentangle  the  bones  from  each  other,  and 
cause  the  head  of  the  displaced  bone  to  recede  into 
its  socket,  or  put  it  in  such  a  position  as  shall  enable 
the  muscles  inserted  into  it  to  draw  it  back  again  into 
its  proper  place. 

Extension  has  for  its  object  the  overcoming  of 
muscular  and  other  resistance  by  a  superior  force, 
and  by  the  application  of  extension  to  the  limb  to 
forcibly  drag  the  bone  back  into  its  normal  situation. 
There  can  be  no  question  as  to  the  superiority  of  the 
former  method,  as  being  the  more  scientific  and  the 
less  likely  to  cause  injury  to  surrounding  structures, 
and  it  should  always  be  employed  in  the  first  instance ; 
extension  being  reserved  for  those  cases  where 
manipulation  has  failed.  Extension  may  be  made  by 
means  of  the  hands  of  the  surgeon  or  his  assistant 
grasping  the  limb  below  the  seat  of  dislocation,  or  if 
thought  necessary,  by  a  bandage  or  jack-towel  fastened 
to  the  limb  by  a  clove  hitch.  Or,  if  more  force  is 
required,  some  form  of  multiplying  pulley  must  be 
employed. 

After  a  dislocation  has  been  reduced,  it  is  necessary 
to  maintain  the  joint  in  a  fixed  position  for  some  days, 
otherwise  the  bono  may  easily  slip  out  of  position 
again,  the  ligaments  which  should  retain  it  in  place 
having  been  stretched  or  torn.  But  this  fixed  position 
should  not  be  maintained  for  too  long,  otherwise 
fibrous  adhesions  between  the  injured  surfaces  may 
take  place,  and  thus  an  impairment  of  the  movements 


UNR  ED  UCE  D   DlSL  OCA  TIONS. 


163 


of  the  joint,  which  it  will  be  very  difficult  to  remedy, 
may  result.  After  about  a  week  or  ten  days  of 
perfect  rest,  the  limb  should  be  loosened  from  the 
bandages  or  splint,  and  passive  motion  should  be 
gently  and  carefully  applied  to  the  joint.  This  pro- 
ceeding should  be  repeated  daily  by  the  surgeon  (the 
limb  being  still  kept  bandaged)  during  the  intervals 


Uui'educed  Dislocation  of  tlie  Femiu*. 


The  acetaViuliim  lias  hocn  partially  filled  with  a  dense  fibroid  material,  and  a  new 
cavity  formed  for  the  head  of  the  thigh  bone.    (After  Astley  Cooper.) 


of  his  visits  for  some  time  longer,  lest  some  incautious 
movement  of  the  patient  should  induce  a  recurrence 
of  the  displacement. 

ITiu'ediiced  dislocations. — If  a  dislocation  is 
allowed  to  remain  unreduced,  great  and  important 
changes  take  place  both  in  the  old  cavity  from  which 
the  bone  has  been  separated,  in  the  displaced  bone  it- 
self, and  in  the  tissues  against  which  it  rests  in  its  new 
position.  In  the  ball-and-socket  joints  the  old  cavity 
generally  becomes  filled  up  with  a  fibroid  material, 


164  Manual  of  Surgery, 

and  its  circumference  becomes  contracted  and  less 
regular;  the  head  of  the  bone  becomes  altered  in  shape ; 
its  encrusting  cartilage  becomes  absorl)ed,  or  else 
becomes  converted  into  a  dense  connective  tissue  ; 
tlie  structures  against  which  the  head  of  the  bone  rests 
become  hollowed  out,  forming  a  cavity  lined  by  a 
dense  fibroid  material,  which  sometimes  partially 
ossifies.  Between  the  two  bones  a  synovial  sac  be- 
comes developed,  and  the  cellular  tissue  around  them 
becomes  infiltrated  with  plastic  matter  and  forms  a 
complete  capsular  investment.  Thus  a  fairly  perfect 
false  joint  is  formed,  in  which,  under  favourable 
circumstances,  a  considerable  range  of  movement  may 
be  allowed.  In  the  hinge  joints  the  articular  ends 
are  altered  in  shape  so  as  to  be  scarcely  recognisable, 
the  bony  processes  become  rounded  ofi",  and  the  ex- 
tremities of  the  bones  present  a  stunted,  angular 
outline ;  the  cartilages  covering  them  become  me- 
tamorphosed into  connective  tissue. 

Secondary  changes  take  place  in  the  neighbouring 
structures  ;  muscles  shorten  and  atrophy,  and,  if  not 
used,  undergo  fatty  degeneration ;  vessels  and  nerves 
become  incorporated  in  the  altered  structures  in  the 
neighbourhood  of  the  new  joint,  and  their  functions 
partially  interfered  with,  and  all  the  injured  tissues 
more  or  less  infiltrated  with  a  dense  cicatricial 
material. 

The  amount  of  movement  which  may  be  obtained 
in  an  unreduced  dislocation  will  depend,  in  a  great 
measure,  on  the  nature  of  the  joint,  very  much  more 
motion,  as  a  rule,  being  possible  in  a  ball-socket  than 
a  hinge  joint. 

In  determining  the  question  as  to  whether  an 
attempt  should  be  made  to  reduce  an  old  dislocation, 
the  introduction  of  anaesthetics  has  led  us  very  con- 
siderably to  modify  the  old  rule  laid  down  by  Sir 
Astley  Cooper,  that  it  was  improper   to  attempt  the 


Dislocations  of  the  Jaw.  165 

reduction  of  a  dislocation  of  tbe  shoulder  which  had 
existed  for  a  longer  period  than  three  months,  or  ot 
the  hip  that  had  been  allowed  to  remain  unreduced 
for  more  than  eight  weeks.  Under  the  influence  of 
an  anaesthetic  dislocations  have  been  reduced  after  a 
much  longer  period  than  this,  though  it  is  always 
doubtful,  when  they  have  existed  for  a  very  long  time, 
whether,  if  reduced,  the  limb  would  gain  or  lose  in 
utility.  In  coming  to  a  decision  as  to  the  advisability 
or  not  of  attempting  reduction,  the  amount  of  pain 
produced  by  moving  the  displaced  bones  on  each 
other  should  always  be  taken  into  account.  If  the 
patient  can  move  his  limb  without  much  pain,  there 
is  a  fair  prospect  of  his  obtaining  a  serviceable  false 
joint ;  but  if,  on  the  other  hand,  any  attempt  to  move 
his  limb  causes  him  pain^  it  is  better  to  attempt  re- 
duction, as  the  patient  will  not  be  induced  to  suiii- 
ciently  exercise  his  false  joint  to  enable  him  to  obtain 
any  great  degree  of  motion  in  it.  In  attempting  the 
reduction  of  an  old-standing  dislocation,  all  adhesions 
must  be  first  thoroughly  broken  down,  and  then  an 
effort  be  made  to  replace  the  bone  by  manipulation  or 
extension. 

Special  Dislocations. 

Dislocation  of  the  lower  jaiv. — The  lower 
jaw  can  only  be  dislocated  in  one  direction,  viz.  for- 
wards (Fig.  32),  unless  accompanied  by  fracture.  One 
or  both  condyles  may  be  displaced.  The  former,  the 
"  bilateral,"  is  the  more  common  of  the  two,  beins 
met  with  in  about  three  to  every  two  cases  of  "  uni- 
lateral "  dislocation. 

Causes. — This  injury  can  only  take  place  when 
the  mouth  is  widely  open.  Under  these  circum- 
stances the  condyle  of  the  jaw  is  situated  near  the 
summit  of  the  eminentia  articularis,  and  either  mus- 
cular contraction  or  violence  may  cause  it  to  become 


t66 


Manual  of  Surgerv. 


displaced  forwards  by  forcing  it  over  the  summit  oi 
the  ridge.  Thus  the  jaw  is  liable  to  become  displaced 
during  the  act  of  yawning,  shouting,  or  vomiting ;  or 
it  has  been  known  to  occur  during  the  extraction  of  a 
tooth,  the  passing  of  a  stomach-pump  tube,  or  in 
taking  a  cast  of  the  mouth. 

Symptoms. — -When  the  dislocation  is  bilateral ^ 
the  mouth  is  wide  open  and  the  lower  jaw  advanced 


Fig.  32.— Dislocation  of  the  Lower  Jaw. 

Showing  the  posiiinn  of  the  cdiidyle  of  tlie  j;i\v  in  dislocation  forwards. 


in  front  of  the  upper.  It  is  iixed  and  almost  im- 
movable. The  chin  is  carried  forwards,  and  the  face, 
when  viewed  in  iirofile,  appears  to  be  elongated.  The 
lips  cannot  be  approximated,  and  hence  there  is  drib- 
l)ling  of  saliva,  and  deglutition  and  speech  are  im- 
paired. The  condyle  can  be  felt  in  front  of  its  natural 
position,  where  a  distinct  hollow  is  to  be  perceived. 

In   the   unilateral  dislocation   the   symptoms  are 
not  so  marked,  and   the  chin  is  generally  inclined  to 


Dislocations  of  the  Clavicle.  167 

the  opposite  side  to  that  on  Avliich  the  dislocation  has 
taken  place.  The  condyle  can  be  felt  in  its  natural 
situation  on  the  sound  side,  and  a  certain  degi'ee  of 
movement  is  possible. 

Treatment. — Reduction  can  usually  be  effected 
by  introducing  the  thumb,  guarded  with  a  napkin, 
into  the  mouth  and  making  pressure  downwards  and 
backwards  on  the  lower  molar  teeth,  at  the  same 
time  that  the  chin  is  elevated  with  the  fingers  ;  or  a 
wedge  may  be  inserted  between  the  molar  teeth  on 
one  or  both  sides,  according  as  the  dislocation  is 
unilateral  or  bilateral,  and  the  chin  forced  directly 
upwards.  Sir  Astley  Cooper  recommends  that  the 
end  of  a  piece  of  wood  about  a  foot  long  should  be 
introduced  between  the  molar  teeth  of  the  two  jaws  ; 
by  raising  the  other  end  of  the  wood,  the  lower  molars 
are  depressed,  the  upper  teeth  acting  as  a  fulcrum,  and 
the  jaw  levered  back  into  its  place.  Nelaton  believed 
that  the  immobility  of  the  jaw  and  the  difficulty  in 
reduction  arose  from  the  coronoid  process  becoming 
fixed  against  the  malar  bone.  He  therefore  recom- 
mends that  reduction  should  be  effected  by  directly 
pressing  on  these  processes  and  forcing  them  back- 
wards. 

After  reduction  the  jaw  is  to  be  fixed  with  a  four- 
tailed  bandage  for  at  least  a  week,  after  which  passive 
motion  must  be  cautiously  and  regularly  applied.  The 
jaw,  having  once  been  dislocated,  is  very  liable  to 
become  again  displaced,  and  in  some  cases  the  struc- 
tures around  the  joint  become  so  lax  that  the  accident 
is  constantly  recurring. 

In  old-standing  dislocations  an  attempt  should 
always  be  made  to  reduce  it,  for,  even  if  it  does  not 
succeed,  the  effort  will  do  some  good  by  increasing 
the  mobility  of  the  bone  in  its  new  situation. 

Dislocation  of  the  claAicle.— The  clavicle 
may  be  dislocated   at    either  extremity  ;  either  fi'om 


i6S 


Ma.yual  of  Surgery. 


tlie  sternum  internally,  or  from  the  acromion  process 
of  tlie  scapula  externally. 

Dislocation  at  the  sternal  end  may  take  place  in 
three  directions,  viz.  forwards,  backwards,  and  up- 
Avards,  named  in  their  relative  order  of  frequency. 

Dislocation  forwards  is  caused  by  violence  ap- 
plied to  the  front  of  the  acromial  end  of  the  bone,  as 

falls  or  severe  blows 
on  the  front  of  the 
shoulder.  This 
causes  the  sternal 
end  of  the  bone  to 
start  forwards,  a 
severe  strain  is  put 
upon  the  ligaments 
of  the  articulation, 
they  give  way,  and 
a  dislocation  results. 
The  end  of  the  bone 
is  thrown  forwards, 
downwards,  and  inwards,  and  rests  on  the  anterior 
surface  of  the  manubrium. 

Symptoms.— The  signs  of  the  injury  are  very 
marked,  the  prominence  of  the  displaced  bone  on  the 
front  of  the  sternum  being  very  characteristic.  The 
shoulder  is  approximated  to  the  median  line,  and  all 
movements  of  the  upper  extremity  are  attended  with 
pain.  The  only  injury  for  which  it  is  liable  to  be  mis- 
taken is  fracture  of  the  sternal  end  of  the  clavicle  ; 
]3ut  the  abrupt  outline  of  the  projection,  and  the 
presence  of  crepitus  is  generally  sufficient  to  dis- 
tinguish this  lesion  from  dislocation. 

Treatment.— Reduction  is  to  be  effected  by 
drawing  the  shoulders  forcibly  backwards,  with  the 
knee  placed  in  the  middle  of  the  patient's  back, 
between  the  two  scapula?.  After  reduction  there  is 
often  the  greatest  difficulty  in   maintaining  the  bone 


33. — Dislocation  of  tlie  Sternal  end 
of  the  Clavicle  forwards. 


Dislocations  of  the  Clavicle.  169 

in  position.  This  is  best  done  by  placing  a  large  pad 
in  the  axilla,  and  applying  a  ligure  of  8  bandage  to 
the  shoulders.  It  is  a  good  plan  to  instruct  the 
patient  to  wear  an  ordinary  hernia  truss  over  the 
joint  for  some  time  after  the  injury,  as  a  recurrence  is 
very  likely  to  occur. 

Dislocation  toacRwards  may  be  produced  either 
by  direct  or  indirect  violence;  by  indirect  violence,  when 
a  force  is  applied  to  the  shoulder,  driving  it  forwards 
and  inwards  ;  or  by  direct  violence  when  a  force  ls 
applied  directly  to  the  inner  end  of  the  clavicle. 
The  articular  end  of  the  bone  may  be  displaced  back- 
wards, and  either  a  little  downwards  or  upwards 
from  its  normal  position ;  in  the  former  instance 
lying  behind  the  first  piece  of  the  sternum,  in  the 
latter  lying  above  the  level  of  the  upper  border  of 
this  bone. 

Symptoms. — There  is  a  well-marked  depression 
at  the  sterno-clavicular  articulation,  and  the  end  of  the 
clavicle  can  be  felt  at  the  front  of  the  neck, 
or  else  it  will  be  found  to  have  disappeared 
behind  the  sternum.  There  is  approximation  of  the 
shoulder  to  the  median  line  of  the  body,  and  pain 
and  inability  to  use  the  extremity.  The  head  is 
inclined  to  the  injured  side.  In  addition  to  this, 
special  symptoms  may  be  present  owing  to  pressure  on 
neighbouring  parts.  There  may  be  dyspnoea  from 
pressure  on  the  trachea  ;  dysphagia  from  pressure  on 
the  oesophagus ;  or  congestion  of  the  head  and  face, 
and  perhaps  even  semicoma,  from  pressure  on  the 
large  veins  at  the  root  of  the  neck. 

Treatment. — Reduction  may  generally  be  accom- 
plished, as  in  the  dislocation  forwards,  by  placing  the 
knee  in  the  middle  of  the  back,  between  the  two 
scapulae,  and  forcibly  drawing  the  two  shoulders  back- 
wards. To  retain  the  bones  in  position  a  large  pad 
sliould   be  placed   over  the   spine   and  a  figure  of  8 


170 


Manual  of  Surgery. 


bandage  tightly  applied  over  the  points  of  the 
shoulders.  There  is  often  great  difficulty  in  retaining 
the  bone  in  its  place,  and  when  this  is  so,  and  there  are 
urgent  symptoms  of  dysphagia  or  dyspnoea,  it  may 
become  necessary  to  excise  the  end  of  the  clavicle. 

Dislocation  iipAvartls  is  of  very  rare  occurrence, 
and  can  only  be  produced  by  indirect  force  applied 
to  the  shoulders   in  a  very  unusual  direction,  so   that 

it  is  forced  down- 
wards and  inwards. 
The  end  of  the  bone 
is  carried  inwards  as 
well  as  upwards,  and 
rests  on  the  uj^per 
border  of  the  ster- 
num, between  the 
sterno  -  mastoid  and 
sterno-hyoid  muscles. 
Syiiiptoms. — 
The  sternal  end  of 
the  clavicle  forms  a 
prominent  swelling 
in  its  new  position,  in  front  of  the  trachea.  The  axis 
of  the  clavicle  is  directed  forwards  and  upwards,  and 
there  is  a  considerable  interval  between  it  and  tlie 
first  rib.  There  is  loss  of  motion  in  tlie  extremity  and 
approximation  of  the  shoulder  to  the  mesial  line  of 
the  body. 

Treatment. — In  order  to  effect  reduction  a 
large  and  hard  pad  should  be  placed  in  the  axilla  to 
act  as  a  fulcrum,  and  the  elbow  pressed  well  in  to  the 
side  of  the  chest.  At  the  same  time  the  end  of  the 
bone  must  be  forced  downwards  by  direct  pressure 
upon  it.  In  oi'der  to  retain  the  bone  in  position  after 
reduction,  a  pad  must  be  placed  in  the  axilla  and  the 
arm  bound  to  the  side,  the  shoulder  being  at  the  same 
time  raised  by  carrying  the  bandage  under  tlie  point 


Fig.  3-t.— Dislooation  of  tlie  Sternal  end 
of  the  Clavicle  upwards. 


Dislocations  of  the  Claviclr 


lyi 


of  the  elbow  and  over  the  opposite  shoulder.  This 
may  be  supplemented,  if  necessary,  by  a  pad  over  the 
joint,  securely  bandaged  so  as  to  make  direct  pressure 
on  the  sternal  end  of  the  bone. 

Dislocation  of  the  acromial  end  of  the  clavicle 
ought  more  correctly  to  be  described  as  dislocation 
of  the  acromion  process 
of  the  scapula,  in  accor- 
dance witli  the  usual 
nomenclature  of  disloca- 
tions, where  the  more 
distal  bone  is  the  one 
usually  spoken  of  as  being 
dislocated. 

This  injury  is  more 
common  than  dislocation 
at  the  sterno  -  clavicular 
joint,  and  almost  invari- 
ably takes  place  in  one 
direction,  that  is  to  say, 
the  clavicle  is  displaced 
upwards  on  to  the  acro- 
mion process.  Some  few 
cases  have,  however,  been 
recorded  where  it  has 
been     displaced     beneath 

this  process.  It  is  generally  caused  by  a  direct  l>low 
on  the  scapula,  especially  if  the  blow  be  given  from 
behind,  so  as  to  drive  the  point  of  the  shoulder  for- 
wards. 

Syiiiptoiiis. — The  signs  of  the  ordinary  dis- 
location are  unmistakable.  There  is  a  marked 
prominence,  produced  by  the  outer  end  of  the  clavicle 
riding  on  the  top  of  the  acromion  process  of  the 
scapula ;  the  shoulder  is  depressed  and  approximated 
to  the  middle  line  of  the  body,  and  the  patient  is 
unable  to  raise  his  arm  upwards  over  his  head. 


Fi£ 


35.— Dislocation  of  the  Acro- 
mial eud  of  the  Clavicle. 


Manual  of  Scrgfry 


Troatiuoiit. — Reduction  can  generally  be  accom- 
])lisliecl  by  drawing  the  points  of  the  shoulders  back- 
wards, and  at  the  same  time  making  direct  pressure 
on  the  prominent  end  of  the  clavicle  ;  but  there  is 
great  difficulty  in  maintaining  the  parts  in  apposition 
after  reduction.  This  is  best  done  by  placing  a  pad 
over  the  joint  and  firmly  strapping  it  in  this  position  by 
a  broad  nebbing  carried  over  it  and  round  the  point  of 
the  elbow,  and  afterwards  binding  the  arm  to  the  side. 
Dif^locatioii  of  the  liiiiiici'ii«».  —  Dislocations 
of  the  shoulder  occur  much  more  frequently  than 
at  any  otlier  articulation.  The  head  of  the  humerus 
may  be  displaced  in  five  different  directions,  viz.  (1) 

forwards,  inwards,  and 
slightly  downwards  (the 
siihcoracoid)  ;  (2)  down- 
wards, and  slightly  for- 
wards, and  inwards  (the 
si(hglenoid)  \  (3)  back- 
wards, inwards,  and 
slightly  downwards  (the 
subspinous) ;  (4)  for- 
wards, iixwards,  and 
upwards  (the  subclavi- 
cular); and  (5)  forwards 
and  upwards  (the  sujrra- 
coracoid). 

1.  Siibcoracoi*!. — 
This  is  by  far  the  most 
conmion  form  of  disloca- 
tion of  the  shoulder  joint. 
The  head  of  the  bone  is  thrown  forwards,  inwards,  and 
■slightly  downwards,  so  tliat  the  anatomical  neck  of 
the  humerus  rests  on  the  anterior  edge  of  the  glenoid 
cavity,  immediately  below  the  coracoid  process  of  the 
scapula.  It  lies  above  the  tendon  of  the  subsca])ularis 
muscle,  which   is   frequently   torn  ;  when  this  is  not 


Fi-.  36. 


-Sul)coracoid  Dislocation  of 
the  Humerus. 


Dislocations  of  the  Humerus.  173 

the  case,  the  neck  of  the  bone  is  embraced  by  the  fibres 
of  the  muscle,  and  this  often  proves  to  be  a  serious 
impediment  to  reduction. 

Causes. — This  form  of  dislocation  may  be  pro- 
duced either  by  a  direct  blow  or  fall  upon  the  shoulder, 
the  force  being  inflicted  in  such  a  manner  as  to  drive 
the  head  of  the  bone  forwards  and  inwards  ;  or  by 
falls  on  the  elbow  or  hand,  when  the  arm  is  extended 
from  the  side.  In  these  latter  cases  it  would  seem 
probable  that  in  many  instances  the  head  of  the  bone 
is  f»i'irnarily  displaced  downwards,  and  that  the 
subsequent  alteration  in  its  position  to  beneath  the 
coracoid  process  is  due  to  muscular  contraction,  or  to 
the  du-ection  in  which  the  violence  was  applied. 

Symptoms. — In  many  particulars  the  signs  of  all 
forms  of  dislocation  of  the  shoulder  joint  are  the  same, 
and  it  is  principally  by  the  alteration  in  the  direction 
of  the  axis  of  the  bone,  by  its  lengthening  or  shorten- 
ing, and  by  the  presence  of  the  head  of  the  bone  in 
its  new  situation,  where  it  can  be  felt,  that  the  differ- 
ential diagnosis  between  the  various  forms  can  be 
established.  The  signs  common  to  all  dislocations  of 
the  shoulders  are  :  (1)  pain ;  (2)  flattening  of  the 
shoulder;  (3)  apparent  projection  of  the  acromion 
process;  (4)  a  depression  beneath  this  process;  (5) 
rigidity  or  impaired  mobility  about  the  joint ;  and  (6) 
the  presence  of  the  head  of  the  bone  in  a  new  situation. 
To  these  may  be  added  two  special  signs,  which  will 
be  found  useful  in  substantiating  the  diagnosis  in 
doubtful  cases.  The  one  was  pointed  out  by  the  late 
INEr.  T.  Callaway  ;  it  consists  in  taking  the  vertical 
circumference  of  any  shoulder  in  which  dislocation 
exists  by  means  of  a  tape  carried  over  the  acromion 
and  under  the  axilla,  when  an  increase  of  about  two 
inches  over  the  sound  side  will  be  found  to  be  an  invari- 
able concomitant.  The  other  is  known  as  Dugas's 
guide.      "If   the  fingers  of  the  injured  limb   can  be 


174 


Manual  of  Surgery. 


|)laced  l)y  the  patient,  or  by  the  surgeon,  upon  the 
sound  shoulder,  while  the  elbow  touches  the  thorax,  a 
condition  that  obtains  in  the  normal  condition  of  the 
joint,  there  can  be  no  dislocation." 

The  principal  signs  by  which  the  subcoracoid  dis- 
location may  be  diagnosed  from  the  other  forms  are  : 
(1)  An  alteration   in  the  direction  of  the  axis  of  the 

bone.  Tlie  elbow 
is  generally  thrown 
backwards  and 
away  from  the  side, 
and  the  bone  is 
directed  inwards, 
away  from  its  nor- 
mal direction.  (2) 
The  head  of  the 
bone  can  some- 
times, in  thin  per- 
sons, be  easily  felt 
beneath  the  cora- 
coid  process ;  but 
in  stout  people  it 
cannot  always  be 
perceived,  though 
even  in  these  there 
is  generally  a  greater  fulness  than  natural  of  the 
anterior  fold  of  the  axilla.  (3)  There  is  usually  a 
Aery  slight  lengthening  of  the  arm. 

2.  Subglenoid. — In  this  dislocation  the  head 
of  the  bone  is  displaced  downwards,  and  at  the  same 
time  a  little  forwards  and  inwards.  It  rests  on  the 
axillary  border  of  the  scapula,  just  below  the  glenoid 
cavity,  between  the  subscapularis  above,  the  long  head 
of  the  triceps  behind,  and  the  teres  muscles  below. 

Causes. — It  is  caused  much  in  the  same  way  as 
the  subcoracoid  dislocation,  by  falls  on  the  elbow  or 
hand  when  the  arm  is  extended  away  from  the  side. 


37. — Subglenoid  Dislocation    of 
Hum  ems. 


the 


Dislocations  of  the  Humerus.  175 

Wlicn  the  arm  is  in  this  position  the  head  of  the  bone 
projects  below  the  lower  margin  of  the  glenoid  cavitj 
and  stretches  the  inferior  part  of  the  glenoid  ligament. 
Any  sudden  force  applied  to  the  limb  while  the  bon-^. 
is  in  this  position  tears  the  ligament,  and  the  head  of 
the  bone  becomes  displaced  downwards  into  the  axilla. 
If  it  remains  in  this  position,  a  subglenoid  dislocation 
is  the  result^  but  in  the  majority  of  instances  it  is 
forced  away  from  this  position  by  a  continuance  of 
the  violence  which  caused  the  primary  displacement, 
or  is  drawn  upwards  by  muscular  action  and  one  of 
the  other  forms  of  dislocation  results. 

Symptoms. — The  common  signs  which  charac- 
terise all  dislocations  of  the  shoulder  are  more  pro- 
nounced in  this  form  than  in  the  preceding,  and  there 
are,  in  addition  to  these,  certain  special  signs  by  which 
this  dislocation  may  be  differentiated  from  the  others. 
The  elbow  is  thrown  considerably  away  from  the 
side,  and  there  is  not  the  same  inclination  backwards 
as  in  the  subcoracoid  variety.  Instead  of  the  fulness 
of  the  anterior  fold  of  the  axilla,  which  was  present 
in  the  subcoracoid  dislocation,  there  is  in  these  cases  a 
depression,  due  to  drawing  downwards  of  the  pectoralis 
major  at  its  attachment  to  the  humerus.  The  head 
of  the  bone  can  be  felt  in  the  axilla,  and  there  is 
considerable  lengthening  of  the  arm. 

3.  Subspinous. — In  this  dislocation  the  head 
of  the  bone  is  driven  backwards  and  downwards,  and 
rests  on  the  back  of  the  scapula  in  the  infraspinatus 
fossa,  immediately  beneath  the  spine  and  between  the 
infraspinatus  and  teres  minor  muscles.  Malgaigne 
has  also  described  another  variety,  in  which  the  head 
rests  beneath  the  acromion  process.  It  seems,  how- 
ever, to  be  merely  a  less  complete  form  of  the  same 
luxation,  and  differs  only  in  the  fact  that  the  symptoms 
are  not  so  marked. 

Causes.  —  This   form     of   dislocation    may     be 


176 


Manual  of  Surgery. 


jH'oduced  by  direct  violence,  i.e.  by  blows  struck  on 
the  front  of  the  shoulder  ;  or  by  indirect  force,  in  the 
same  way  as  the  subcoracoid  dislocation,  the  initial 
displacement  being  downwards,  and  the  head  of  the 
bone  being  subsequently  forced  or  drawn  into  its 
position  beneath  the  spine.  The  reason  v/hy  the  dis- 
placement in  these  cases  is  generally  forwards  (sub- 
coracoid), is  probably  on 
account  of  the  great 
jjectoral  muscle,  passing 
from  the  front  of  the 
chest  to  the  upper  part 
of  the  humerus,  having  a 
tendency  to  pull  the  bone 
in  this  direction. 

Symptoiiis.— In  the 
subspinous  dislocation,  in 
addition  to  the  symptoms 
common  to  all  forms,  we 
find  that  the  axis  of  the 
humerus  is  directed  back- 
wards, so  that  the  elbow 
is  advanced  in  front  of 
the  body,  and  the  bone  is 
at  the  same  time  rotated 
inwards,  so  that  the  fore- 
arm is  thrown  across  the  front  of  tlie  chest.  There 
is  some  lengthening  of  the  arm.  The  head  of  the 
bone  forms  a  considerable  prominence  on  the  dorsum 
of  the  scapula,  and  there  is  a  marked  depression 
beneath  the  'joracoid  process. 

4.  Subclavicular. — This  form  of  dislocation  is 
very  rare,  and  is  an  exaggerated  form  of  the  sub- 
coracoid. The  head  of  the  bone  is  thrown  forwards 
and  inwards,  and  also  upwards,  so  that  it  rests  on  the 
front  of  the  chest,  internal  to  the  coracoid  process,  and 
immediately  beneath  the  clavicle. 


Fig.   38. — Subspinous     Dislocaiiou 
of  the  Humerus. 


Dislocations  of  the  Humerus. 


177 


Causes. — The  dislocation  requires  great  force  to 
produce  it,  and  is  caused  by  tlie  head  of  the  bone  being 
violently  driven  against  the  anterior  part  of  the  caj)- 
sular  ligament.  There  is,  therefore,  in  these  cases 
considerable  lace- 
ration of  the  mus- 
cles attached  to  the 
tuberosities  of  the 
humerus. 

Symptoms.— 
There  is  generally 
no  dithculty  in  at 
once  coming  to  a 
decision  as  to  the 
nature  of  the  case, 
the  presence  of  the 
head  of  the  bone 
in  its  new  situation 
being  most  pal- 
pable, so  that  it 
can  be  not  only 
felt,       but       seen, 

forming  a  globular  prominence  beneath  the  pectoral 
muscle.  On  account  of  the  great  displacement, 
the  acromion  is  very  prominent,  and  the  hollow 
beneath  it  well  marked.  There  is  shortening  of  the 
arm,  and  the  elbow  is  carried  outwards  and  back- 
wards. 

5.  Siipracoracoid.  — This  is  a  mixed  form  of 
accident,  the  dislocation  being  secondary  to  fracture 
of  the  coracoid  process.  The  head  of  the  bone  rests 
between  the  fractured  coracoid  and  acromion  processes, 
in  contact  with  the  anterior  border  of  the  clavicle. 
As  far  as  I  am  aware,  only  three  cases  of  this  injury 
have  been  recorded. 

Treatment. — There  are  three  different  modes  of 
I'educing    dislocations  of   the  shoulder  joint :    (1)    by 
M— 21 


Fig.  39. —Subclavicular    Dislocation  of  the 
Humerus. 


TTg  Manual  of  Surgery. 

manipulation ;  (2)  by  extension ;   (3)  by  mechanical 
appliances. 

By  manipulation. — The  simple  plan  recently  in- 
troduced by  Kocher  appears  to  be  the  most  efficient 
means  of  reducing  dislocations  by  manipulation.  The 
patient  is  seated  in  a  chair,  and  the  surgeon,  standing 
in  front  of  him,  gently  presses  the  elbow  to  the  side, 
the  fore-arm  having  first  been  flexed  on  the  arm.  The 
humerus  is  now  rotated  outwards  until  the  fore-arm  is 
at  a  right  angle  with  the  body.  In  many  cases  this  is 
all  that  is  necessary,  and  the  head  of  the  bone  will  be 
felt  to  recede  into  its  place.  Should  it  not  do  so,  the 
elbow  is  now  to  be  raised  from  the  body  and  rotated 
inwards,  until  the  hand  reaches  the  opposite  shoulder. 

By  extension. — There  are  several  plans  by 
which  dislocations  of  the  shoulder  may  be  reduced  by 
extension.  The  simplest  and  best  is  by  the  heel 
in  the  axilla.  The  patient  is  placed  on  a  low  couch, 
and  the  surgeon,  seated  on  its  edge  and  facing  the 
patient,  places  his  heel  in  tlie  axilla,  and,  taking  the 
patient's  wrist,  draws  the  arm  steadily  downwards. 
After  sufficient  extension  has  been  made,  should  the 
bone  not  recede  into  its  place,  as  it  often  does,  he 
brings  the  arm  across  the  front  of  the  patient's  chest. 
The  foot  then,  acting  as  a  fulcrum,  forces  the  head  of 
the  bone  upwards  and  outwards,  and  so  effects  re- 
duction. Another  plan,  which  sometimes  succeeds 
when  others  fail,  consists  in  laying  the  patient  flat  on 
his  back,  and  having  fixed  the  scapula  by  means  of  a 
jack-towel  passed  over  the  shoulder  girdle,  and  held 
by  an  assistant  standing  at  the  foot  of  the  bed,  making 
extension  vertically  upwards. 

Many  other  plans,  too  numerous  to  mention,  have 
been  advocated  at  different  times,  all  of  which  have 
proved  efficient.  It  will  generally  be  found,  however, 
that  one  or  the  other  methods  mentioned  above  will 
succeed  in  effecting  reduction,  unless  in  the  case  of 


Dislocations  of  the  Humerus.  179 

old  unreduced  dislocation,  when  it  may  be  necessary 
to  have  recourse  to  the  pulleys. 

By  'pulleys. — The  patient  having  been  brought 
thoroughly  under  the  influence  of  an  anaesthetic,  all 
adhesions  are  to  be  thoroughly  broken  down.  The 
scapula  is  fixed  by  a  leather  collar,  which  encircles  the 
shoulders,  and  is  fastened  to  a  staple  on  the  sound  side 
of  the  patient.  The  pulleys  are  to  be  attached  to  the 
lower  end  of  the  humerus,  and  extension  made  in  a 
horizontal  direction  and  continued  until  the  head  of 
the  bone  is  felt  to  move,  when  the  surgeon  should 
endeavour  to  manipulate  or  push  the  bone  into  place. 
After  reduction  the  arm  must  be  bandaged  to  the  side, 
with  a  pad  in  the  axilla,  and  maintained  in  this  position 
for  a  week.  Passive  motion  must  then  be  commenced. 
The  surgeon  must  daily  remove  the  bandage,  and  care- 
fully and  cautiously  move  the  joint  in  every  direction ; 
the  arm  being  still  kept  bandaged^  between  his  visits, 
for  another  three  weeks,  when  the  patient  may  be 
allowed  to  begin  to  use  his  arm,  at  first  with  care, 
and  he  should  avoid  all  violent  exercise  for  some  time 
longer. 

Accidents  occasionally  occur  in  reducing  old- 
standing  dislocations  of  the  shoulder  joint.  Of  these, 
rupture  of  the  axillary  artery  is  the  most  common,  and 
would  appear  to  result,  in  some  cases,  from  the  vessel 
having  become  adherent  to  the  bone,  and  becoming 
lacerated  in  breaking  down  the  adhesions.  The  axillary 
vein  may  also  be  injured,  though  less  commonly  than 
the  artery.  The  humerus  may  be  fractured,  the 
brachial  plexus  bruised  or  lacerated,  and  finally  the 
skin,  subcutaneous  tissue,  and  muscles  torn,  as  the 
result  of  excessive  force  employed  in  the  reduction  of 
a  dislocation. 

In  determining  the  point  as  to  whether  an  at- 
tempt should  be  made  to  reduce  an  old  standing  dis- 
location of   the   shoulder,  a  great  deal  njust    depend 


i8o 


Manual  of  Surgery 


upon  the  amount  of  motion  which  the  patient  enjoys, 
and  how  far  this  motion  can  be  carried  on  without 
pain.  If,  after  three  months  or  longer,  there  is  a  fair 
amount  of  movement  of  tlie  head  of  the  bone  in  its 
new  situation,  it  is  better  to  abandon  all  attempts  at 
reduction,  since  the  patient  will  probably  have  a  more 
useful  arm  than  if  the  attempt  at  reduction  succeeded, 
without  being  exposed  to  the  risks  which  must  attend 
such  a  proceeding. 

Dislocation  of  the  elbow.  —  Dislocation  of 
the  elbow  joint  is  a  common  accident,  occurring  fre- 
quently in  young  people.  Both  bones  may  be  dis- 
placed backwards,  forwards,  inwards,  or  outwards  ;  or 
a  combination  of  two  of  these  forms  may  occur,  and 
lioth  bones  be  dislocated  backwards  and  outwards,  or 

backwards  and  in- 
wards. One  bone  only 
may  be  displaced ; 
thus,  the  ulna  may 
alone  be  displaced 
])ack wards,  or  the  ra- 
dius may  be  dislocated 
forwards,  backwards, 
or  outwards. 

Dislocation  ot 
both  hones  of  the 
fore  -  arm  hack- 
wards. — Tliis  is  by 
far  the  most  common 
luxation  of  the  elbow, 
and  is  usually  caused 
by  falls  on  the  palm  of  the  hand.  The  dislocation 
may  be  complete  or  incomplete.  In  the  complete  form 
the  coronoid  process  of  the  ulna  is  lodged  in  the 
olecranon  fossa  of  the  humerus,  while  in  the  incom- 
plete form  it  rests  on  the  trochlear  surface  of  the  bone. 
In  some  cases  the  dislocation   is    complicated    with 


Fig.  40. — Dislocation  of  both  Bones  of 
the  Fore-arm  backwards. 


Dislocations  of  the  Elbow. 


i8i 


fracture    of  the  coronoid  process,  but    as   a  rule  this 
does  not  occur. 

Syniptoiiis* — There  is  considerable  deformity 
about  the  joint,  the  olecranon  stands  out  prominently 
behind  the  elbow,  and  the  triceps  can  be  felt  to  be 
separated  from  the  bone.  In  front  of  the  joint  the 
rounded  end  of  the  humerus  can  be  plainly  perceived. 
The  head  of  the  radius  forms  a  globular  swelling 
])ehind  the  external  condyle.  The  fore-arm  is  flexed 
and  supinated,  and  there  is  undoubted  shortening. 
The  injury  may  be  mistaken  for  transverse  fracture 
of  the  lower  end  of  the  shaft  of  the  humerus  ;  but  in 
these  cases  the  relative  position  between  the  condyles 
and  the  olecranon  pro- 
cess is  unaltered,  and 
this  constitutes  a  ready 
means  of  distinguishing 
the  one  injury  from  the 
other. 

Dislocation  ot 
both  bones  of  tlie 
forc-arni  foi'Avards. 
— This  is  a  very  rare 
form  of  dislocation,  and 
can  only  take  place  when 
the  fore-arm  is  in  a  con- 
dition of  extreme  flexion, 
and  usually  occurs  from 
falling  backwards  on  the  i)oint  of  the  elbow.  The 
dislocation  may  be  complete  or  incomplete.  When 
complete  the  olecranon  is  quite  in  front  of  the  con- 
dyles ;  in  the  incomplete  form  the  tip  of  this  process 
rests  against  the  articular  surface  of  the  humerus. 

Symptoms.  —  The  fore-arm  is  considerably 
lengthened  and  usually  bent  on  the  arm.  The 
l)rominence  of  the  olecranon  is  entirely  lost,  and  the 
condyles  of    the  humerus  can  be  felt  at  the  back   of 


Fig.  41. — Dislocation  of  the  Bones  of 
the  Fore-arm  forwards.  (After 
Brjaut.) 


i82  Manual  of  Surgery. 

the  joint,  with  the  triceps  muscle  tightlj  stretched 
over  them.  The  sigmoid  cavity  of  the  uhia  and  the 
head  of  the  radius  can  usually  be  felt  at  the  front  of 
the  bend  of  the  elbow. 

JLatoral  dislocation  of  t>otSi  l>oiics  of  the 
fore-arm. — The  lateral  dislocations  of  the  elbow  are 
almost  always  incomplete,  the  luxation  outwards  being 
the  more  common  of  the  two.  In  the  outward  dislo- 
cation, the  sigmoid  cavity  of  the  ulna  rests  against 
the  capitellum  or  radial  head  of  the  humerus,  and 
the  radius  projects  beyond  the  external  condyle.  In 
the  dislocation  inwards,  the  sigmoid  cavity  of  the  ulna 
rests  against  the  internal  condyle,  and  in  consequence 
of  the  fore-arm  becoming  pronated  the  head  of  the 
radius  lies  a  little  below  and  in  front  of  the  articular 
surface  of  the  humerus. 

Symptoms. — In  both  forms  of  dislocation  tliere 
is  great  distortion  and  increased  width  of  the  joint. 
The  fore-arm  is  flexed  and  pronated.  In  the  dislocation 
outwards  the  head,  of  the  radius  can  generally  be 
recognised  forming  a  prominent  swelling,  and  in  the 
dislocation  inwards  there  is  a  marked  and  elongated 
projection  on  the  inner  side  of  the  joint,  caused  by 
the  internal  border  of  the  great  sigmoid  cavity.  In 
both  the  relation  of  the  olecranon  to  the  condyles  is 
altered. 

The  dislocations  backwards  and  outwards  and  ha/ik- 
vsards  and  inwards  differ  from  the  common  dislocation 
backwards  merely  in  the  fact  that  the  bones  of  the 
fore-arm  are  thrown  a  little  to  the  radial  or  ulnar  side 
of  their  normal  position,  and  therefore  the  tip  of  the 
olecranon  will  be  found  to  be  approximated  to  one  or 
the  other  condyle. 

Dislocation  of  tlie  ulna  alone  is  a  very 
rare  form  of  injury,  and  one  about  which  we  know 
very  little.  It  always  takes  place  backwards,  and 
may  be  recognised  by  the  projection  of  the  olecranon 


Dislocations  of  the  Radius.  183 

behind  the  joint,  at  the  same  time  that  the  head  of 
the  radius  is  felt  rotating  in  its  natural  position. 

Treatment. — In  all  the  above  described  dislo- 
cations, reduction  can  generally  be  etFected  by  the 
same  plan.  The  patient  is  seated  on  a  chair,  and  the 
surgeon,  standing  in  front  of  him,  places  his  foot  on  the 
chair  and  his  knee  in  the  bend  of  the  injured  elbow, 
80  that  it  shall  press  against  the  upper  part  of  the 
bones  of  the  fore-arm.  He  at  the  same  time  takes 
hold  of  the  patient's  wrist  and  slowly  and  forcibly 
bends  the  fore-arm,  and  the  reduction  is  soon  effected. 
Others  recommend  that  the  knee  should  be  pressed 
against  the  lower  end  of  the  humerus,  and  the  fore- 
arm forcibly  extended,  and  theji  flexed.  In  old- 
standing  dislocations  all  adhesions  must  first  be 
thoroughly  broken  down  before  any  attempt  is  made 
at  reduction^  and  in  some  cases  it  will  be  found 
necessary  to  resort  to  pulleys.  It  rarely  happens  that 
reduction  can  be  effected  after  a  longer  period  than 
five  or  six  weeks,  and  there  is  great  danger  in  using 
the  pulleys,  if  much  force  is  employed,  of  fracturing 
the  humerus. 

Dislocatioii  of  the  head  of  the  radius.— 
The  head  of  the  radius  may  be  dislocated  backwards 
SLnd  forwards,  and  also,  though  rarely,  in  a  direction 
outwards.  There  appears  to  be  considerable  difference 
of  opinion  as  to  whether  the  forward  or  backward 
dislocation  is  the  more  common.  The  injury  in  both 
cases  is  produced  in  the  same  way,  by  falls  on 
the  hand :  in  the  one  instance,  the  lower  end  of 
the  radius  being  driven  backwards  and  the  head 
tilted  forwards,  producing  the  anterior  dislocation ; 
in  the  other  the  whole  bone  being  driven  back- 
wards and  the  head  displaced  on  to  the  back  of  the 
condyle. 

In  the  forward  dislocation  the  fore-arm  is  semi- 
flexed  and   fixed   midway   between    supination    and 


184  Manual  of  Surgery. 

pronation,  and  the  head  of  the  radius  can  be  felt  in 
the  hollow  just  above  the  external  condyle. 

In  the  backward  dislocation  the  fore-arm  is  slightly 
flexed  and  maintained  in  a  position  of  pronation.  The 
limb  is  inclined  outwards  from  the  elbow  point.  Tlie 
head  of  the  radius  can  be  felt  forming  an  easily 
recognised  projection  behind  the  external  condyle. 

Dislocation  outwaiMl  is  a  very  rare  form  of 
injury,  in  which  the  head  of  the  bone  is  displaced 
outwards  and  upwards  above  the  external  condyle.  It 
can  be  easily  detected  in  this  situation  beneath  the 
skin^  which  is  tightly  stretched  over  it,  and  can  be 
felt  rotating  during  supination  and  pronation  of  the 
fore-arm. 

Treatment. — These  various  dislocations  of  the 
radius  may  be  reduced  in  the  same  way.  The  upper 
arm  is  to  be  grasped  by  an  assistant  just  above  the 
elbow,  and  firmly  held.  The  surgeon  then  extends 
the  wrist,  and  after  he  judges  that  sufficient  exten- 
sion has  been  madcj  suddenly  flexes  the  fore-arm  on 
the  arm,  at  the  same  time  endeavouring  to  push  the 
head  of  the  radius  back  into  its  place. 

Dislocation  of  the  ^vrist  is  a  very  rare  acci- 
dent, and  is  caused  by  falls  on  the  hand.  The  bones 
of  the  carpus  may  be  displaced  either  backwards  or 
forwards,  the  former  being  much  the  more  common 
accident  of  the  two ;  and  the  deformity  which  is 
produced  resembles  very  much  a  Colles's  fracture,  but 
the  position  of  the  styloid  processes  and  their  relation 
to  each  other  and  to  the  bones  of  the  hand  at  once 
establishes  the  distinction.  These  dislocations  are  to 
be  reduced  by  extension. 

Dislocation  of  the  radius  from  the  ulna  may  take 
place  at  tlie  radio-carpal  joint  from  violent  twists. 
The  radius  may  be  displaced  either  forwards  or  back- 
wards. 

The  carpal  bones  are  not  often  displaced  from  one 


Dislocations  of  the    Wrist. 


185 


another, 
head    of 


Tlie  most  frequent  dislocation  is  that  of  the 
the    OS    inagnum,    from     violence,     during 
extreme   flexion  of  the  wrist.     The  head  of  the  bone 
easily    to  be  recognised  as   a  prominent    globular 


IS 


swelling  on  the  dorsum  of  the  hand. 

The  most  common  dislocation  in  the  hand  is  that 
of  the  proximal  phalanx  of  the  thumb  from  its  meta- 
carpal bone.  The 
phalanx  is  gene- 
rally displaced 
backwards,  and 
the  head  of  the 
metacarpal  bone 
being  driven  for- 
wards is  button- 
holed between  the 
two  bellies  of  the 
flexor  brevis  pol- 
licis,  often  causing 
great  difficulty  in 
reductioiL  The 
thumb  presents  a 
very  characteris- 
tic deformity.  The 
proximal  phalanx 
is  bent  backwards 
almost  to  a  right 
angle  with  the 
metacarpal  bone, 

and  at  the  same  time  the  terminal  phalanx  is  flexed. 
The  head  of  the  metacarpal  bone  can  be  felt  on  the 
palmar  aspect.  Reduction  is  to  be  effected  by  forcibly 
adducting  the  metacarpal  bone  into  the  palm  of  the 
hand,  by  bending  the  phalanges  backwards  and 
hyper-extending,  and  then,  by  suddenly  flexing  the 
thumb  on  the  metacarpal  bone,  reduction  may  be 
accomplished.     If  this  does    not    succeed  it  will    be 


Fig, 


42.— Dislocation  of  the  Metacarpo-pbalau- 
geal  Joint  of  the  Thixmb. 


i86  Manual  of  Surgery. 

necessary  to  divide  siibcutaneously  the  tendons  of  the 
flexor  brevis  pollicis,  or,  as  Dr.  Humphrey  has  sug- 
gested, draw  them  aside  with  a  hook,  introduced 
through  an  incision  made  on  either  side  of  the  joint. 
Liixations  of  the  other  joints  but  rarely  happen,  except 
as  the  result  of  severe  crushing  violence,  and  present 
nothing  special  as  to  their  nature  or  treatment. 

Dislocation  of  the  liip. — The  hip  joint  may 
be  dislocated  in  four  difierent  directions,  viz.  (1) 
upwards  and  backwards,  on  to  the  dorsum  of  the 
ilium,  (2)  backwards,  into  the  sciatic  notch,  (3)  down- 
wards, into  the  obturator  foramen,  and  (4)  inwards,  on 
to  the  pubes.  It  must  be  borne  in  mind,  however, 
that  the  head  of  the  bone  does  not  always  occupy 
the  same  position  in  these  dislocations,  but  may,  as 
Mr.  Bryant  says,  "rest  at  any  point  around  its 
jacket."  These  varieties  are  therefore  only  adopted 
for  purposes  of  classification  and  description,  and  as 
indicating  generally  the  various  directions  in  which 
the  head  of  the  bone  may  be  displaced. 

Causes. — There  seems  to  be  very  good  ground 
for  believing  that  the  majority  of  luxations  of  the 
hip,  unattended  with  fracture,  are  primarily  disloca- 
tions downwards,  and  are  produced  w^hile  the  thigh 
is  in  a  condition  of  forced  abduction,  and  that  the 
position  which  the  head  of  the  bone  will  subse- 
quently occupy  depends  upon  the  amount  of  flexion 
and  rotation  which  may  be  present  at  the  moment 
of  the  accident.  When  the  thigh  is  abducted  the 
greatest  strain  is  put  upon  the  weakest  part  of  the 
capsular  ligament.  The  head  of  the  femur  bulges  over 
the  lower  and  inner  shallow  margin  of  the  cotyloid 
cavity,  and  presses  against  and  strains  the  lower  and 
inner,  that  is,  the  weakest  part,  of  the  capsular  ligament. 
If  any  severe  force  is  now  applied  this  portion  of 
the  ligament  gives  way,  and  the  head  of  the  bone 
is  primarily  displaced  downwards.     If  at  this  time  the 


Dislocations  of  the  Hip. 


187 


limb  is  in  a  condition  of  Mexion  and  inward  rotation, 
the  initial  violence  which  produced  the  dislocation 
being  continued,  the  head  of  the  femur  is  forced 
round  the  lower  and  outer  margin  of  tlie  cavity, 
and  dislocation  backwards,  or  backwards  and  up- 
wards, is  the  result.  If,  on  the  other  hand,  the  thigh 
is  extended  and  rotated 
outwards,  the  head  of 
the  bone  is  forced  in 
the  opposite  direction, 
round  the  inner  margin 
of  the  cavity,  producing 
dislocation  on  to  the 
piibes.  Whereas,  if  the 
abduction  is  unaccom- 
panied by  rotation  in 
either  direction,  the  bone 
remains  in  the  primary 
position  into  wdiich  it 
was  displaced,  that  is  to 
say,  downwards.  Though 
this  is  true  of  the  ma- 
jority of  dislocations  of 
the  hip,  it  seems  probable 
that  the  dislocation 
backwards      can       take 

place  directly,  and  this  even  without  fracture  of  the 
acetabulum. 

dislocation  on  f  o  the  dorsnni  ilii. — This  is 
the  most  common  form  of  dislocation  of  the  hip, 
occurring  as  frequently  as  the  other  three  dislocations 
together.  The  head  of  the  bone  generally  rests  on 
the  dorsum  of  the  ilium,  just  above  the  facet  which 
marks  the  origin  of  the  reflected  head  of  the  rectus 
muscle,  but  may  vary  in  position.  Sometimes  it  is 
situated  considerably  higher  on  the  dorsum  ;  sometimes 
in  advance  of  this  position,  in  some  cases  so  much  so 


Fig.    43. — Dislocation    on    to    the 
Dorsum  of  the  IHiun. 


1 88  Manual  of  Surgery. 

that  the  head  of  the  bone  rests  iu  the  notch  between 
the  anterior  superior  and  anterior  inferior  spinous  pro- 
cesses of  the  ilium.  This  is  known  as  the  "  sujjra- 
spinous  "  dislocation.  The  head  of  the  bone  is  always 
above  the  obturator  internus  muscle,  and  it  is  from 
this  circumstance  that  Bigelow  distinguishes  it  from 
the  sciatic  dislocation ;  the  one  luxation  being 
"above,"  the  other  "below  the  obturator  internus." 

Symptoms. — There  is  a  marked  distortion  about 
the  hip,  which  appears  to  be  wider  and  flatter  than 
natural.  The  trochanter  is  less  prominent,  and  ap- 
proximated to  the  crest  of  the  ilium  ;  the  head  of  the 
bone  can  generally  be  felt  beneath  the  glutei  muscles  ; 
the  limb  is  considerably  shortened,  sometimes  as 
much  as  two  or  three  inclies  ;  the  thigh  is  flexed, 
rotated  inwards  and  adducted  so  that  the  axis  of  the 
femur  runs  across  the  lower  third  of  the  sound  thigh, 
and  if  the  patient  were  in  the  erect  position  the  ball 
of  the  great  toe  would  rest  on  the  sound  ankle.  The 
voluntary  movements  of  the  joint  are  quite  abolished, 
and  only  a  slight  amount  of  passive  flexion,  adduc- 
tion, and  inversion  is  permitted.  The  vessels  in  the 
groin  may  be  noticed  to  have  lost  their  su])port,  and 
a  hollow  behind  them  can  generally  be  easily  per- 
ceived. The  dislocation  may  be  diagnosed  from 
fracture  of  the  neck  of  the  thigh  bone  by  the  fixed 
position  of  the  limb,  by  the  inversion,  by  the  absence 
of  crepitus,  and  the  presence  of  the  head  of  the  bone 
in  its  new  position. 

Treatment* — An  endeavour  should  always  be 
made,  in  the  flrst  instance,  to  efiect  reduction  by 
manipulation.  The  patient  must  be  placed  on  his 
back  on  a  low  couch  or  the  floor,  and  thoroughly 
anaesthetised.  The  surgeon  stands  over  his  patient 
and  flexes  the  leg  on  the  thigh  and  the  thigh 
on  the  pelvis.  The  flexion  is  to  be  carried  to  its 
extreme    limits ;  the   knee   being   at   the    same  time 


Dislocations  of  the  Hip.  189 

somewhat  adducted  and  brought  well  over  the  middle 
line  of  the  body.  While  the  flexion  is  maintained 
the  limb  is  to  be  abducted  to  its  fullest  extent,  and 
then  rotated  outwards  and  brought  suddenly  down 
into  the  extended  position.  By  this  series  of  man- 
oeuvres the  head  of  the  bone  will  be  made  to  retrace  the 
steps  by  which  it  has  been  dislocated,  and  reduction 
will  generally  be  accomplished.  Should  it  not  succeed, 
recourse  must  be  had  to  extension  by  means  of  pulleys. 
The  patient  must  be  laid  on  his  sound  side,  and  the 
pelvis  fixed  by  a  perineal  band  attached  to  some 
stationary  object  behind  the  patient's  head.  The 
pulleys  are  to  be  connected  to  the  lower  part  of  the 
thigh,  which  is  to  be  flexed  on  the  abdomen,  and  exten- 
sion made  at  right  angles  to  the  trunk.  Sir  Astley 
Cooper  recommended  that  the  patient  should  be  laid 
on  his  back  and  extension  made  across  the  lower 
third  of  the  sound  thigh.  But  this  plan  would  en- 
danger the  integrity  of  the  ileo-femoral  ligament, 
which  must  be  tense,  with  the  thigh  extended ; 
whereas,  it  is  relaxed  when  the  thigh  is  flexed  and 
would  thus  facilitate  reduction. 

2.  Dislocation  backwards. — In  this  dislo- 
cation the  head  of  the  bone  may  rest  on  any  part  of 
the  posterior  surface  of  the  ischium,  below  the  ob- 
turator intern  us  muscle.  It  may  rest  on  the  margin 
of  the  notcli,  or  on  the  structures  passing  through  it. 
It  may  rest  on  the  spine  of  the  ischium  or  against  the 
tuberosity,  opposite  the  smaller  sacro-sciatic  foramen. 

Symptoms. — The  signs  by  which  the  dislocation 
backwards  is  characterised  are  very  similar  to  those 
of  the  iliac  dislocation,  but  are  less  pronounced  and 
less  marked.  There  is  distortion  and  flattenins:  about 
the  hip,  and  the  trochanter  is  displaced,  thougli  not 
to  the  same  extent  as  in  the  former  dislocation  ;  it  is 
usually  a  little  above  and  some  distance  behind  its 
normal  situation.     There  is  shortening  to  the  extent 


190 


Manual  of  Surgery. 


of  aVjout  an  inch.  The  thigh  is  flexed,  rotated  iii' 
wards  and  adducted,  though  to  a  less  extent  than  in 
the  dorsal  dislocation.  So  that,  with  the  patient  in 
the  erect  position,  the  ball  of  the'  great  toe  rests  on 
the  great  toe  of  the  sound  foot.  The  axis  of  the 
femur  is  directed  across  the  sound  knee,  instead  of 
across  the  lower  third  of  the  thigh.  The  facility  with 
wdiich  the  head  of  the  bone  can  be  felt  will  depend  in 

a  great  measure 
upon  its  position. 
In  some  cases  it 
can  be  made  out 
with  ease;  in 
others  it  can  only 
be  perceived  with 
the  greatest  difli- 
culty,  or  perhaps 
not  at  all.  Active 
movement  and  al- 
most all  passive 
movement  is  abol- 
ished, flexion  being 
the  only  motion 
which  is  permitted. 
Treatment.— 
Reduction  is  to  be 
effected  in  the 
same  manner  as  was  employed  for  the  dorsal  disloca- 
tion, and  will  generally  be  accomplished  by  manipula- 
tion, witlioutthe  aid  of  the  pulleys.  By  flexing  the  thigh 
on  the  pelvis,  abducting  and  rotating  outwards,  the 
head  of  the  bone  is  made  to  retrace  its  steps,  just  as 
in  the  dorsal  dislocation,  and  it  is,  without  difficidty 
or  any  great  expenditure  .  of  force,  returned  to  its 
socket.  If  failure  should  attend  the  attemi)t  to  re- 
duce the  dislocation  by  manipulation,  the  pulleys  nnist 
be    applied  in  the  same  manner  as  in  the  previous 


Fig.  4i. 


-Dislocation  backwards  of  the  Head 
of  the  Femur. 


Dislocations  of  the  Hip. 


191 


case.  The  patient  must  be  laid  on  his  sound  side, 
and  with  the  thigh  flexed  as  much  as  possible  on  the 
pelvis,  extension  made  at  right  angles  to  the  trunk. 
This  may  be  supplemented,  if  there  is  any  difficulty, 
by  a  bandage  or  towel  placed  under  the  upper  part  of 
the  thigh  and  pulled  directly  upwards.  This  will  assist 
in  raising  the  head  of 
the  bone  over  the  mar- 
gin of  the  acetabulum. 

3.  Dislocation 
into  the  obturator 
foramen.  —  In  this 
dislocation  the  head  of 
the  bone  generally  rests 
on  the  obturator  ex- 
ternus  muscle,  close  to 
tlie  inner  margin  of  the 
obturator  foramen ;  but 
in  some  instances  it 
may  be  displaced  still 
farther  inwards,  and 
rest  on  the  rami  of  the 
pubes  and  ischium,  at 
about  their  point  of 
junction. 

Symptoms . — 
There  is  an  appearance 
of  flatteninsf  and  de- 
formity  about  the  hip.  The  trochanter  is  not  so 
prominent  as  natural,  and  in  its  normal  position  there 
is  a  depression.  The  fold  of  the  buttock  is  on  a  lower 
level  than  on  the  sound  side,  and  there  is  a  hollow 
in  front  below  the  middle  of  Poupart's  ligament. 
If  the  patient  is  in  the  erect  position,  the  body  will 
be  bent  forwards,  owing  to  the  psoas  and  iliacus 
being  put  on  the  stretch,  and  will  be  tilted  over  to 
the  injured  side,  from  obliquity  of  the   pelvis.      This 


Fig.  45. — Dislocation  of  tlie  Femur 
downwards  into  tlie  Obturator 
Foramen. 


192  Manual  of  Surgery. 

will  give  the  appearance  of  very  considerable  length- 
ening, though  the  actual  amount  is  very  slight,  and  in 
some  recorded  cases  no  increase  in  length  has  been 
found  after  the  most  careful  measurement.  The  limb 
is  abducted  and  advanced  in  front  of  the  other,  and 
the  toes  are  generally  pointed  straight  forwards, 
though  in  some  cases  there  may  be  slight  eversion. 
The  adductor  muscles  are  stretched  and  form  a  tense 
cord,  extending  from  the  pubes  to  the  middle  of  the 
thigh.  The  facility  with  which  the  head  of  the  bone 
can  be  felt  depends  upon  its  position.  If  it  rests  on 
the  obturator  membrane,  it  cannot  be  distinctly  felt 
through  the  muscles;  but  if  it  is  displaced  farther 
inwards  and  rests  on  the  rami  of  the  pubes  and 
ischium,  it  can  easily  be  felt  in  the  perinseum,  and 
sometimes  even  the  dimple  on  it  can  be  detected 
beneath  the  tense  skin.  A  certain  amount  of  passive 
motion  is  possible,  and  the  patient  may  soon  be  able 
to  perform  a  certain  amount  of  flexion  by  his  own 
efforts,  but  any  attempt  at  extension  is  attended  with 
severe  pain.  Patients  in  whom  this  dislocation  has 
been  allowed  to  remain  unreduced,  are  often  able  to 
walk  without  pain,  and  with  very  little  difficulty. 

Treatineiit* — This  form  of  dislocation  can 
generally  be  reduced  by  manipulation.  The  patient 
is  to  be  laid  on  the  floor,  and  the  surgeon,  standing 
over  him,  grasps  the  ankle  with  one  hand  and  the 
knee  with  the  other,  and  flexes  the  thigh  on  the 
pelvis,  at  the  same  time  slightly  abducting  it.  He 
then  rotates  the  thigh  forcibly  inwards,  and,  adducting 
it,  brings  the  knee  down  to  the  floor  by  a  movement  of 
extension. 

Another  plan,  which  is  said  to  answer  equally  well, 
consists  in  circumducting  the  knee  inwards  after 
flexion,  until  it  is  brought  as  far  as  the  middle  line  of 
the  body ;  then  rotating  outwards  and  extending  tl.e. 
thigh. 


Dislocations  of  the  Hip. 


193 


A  combination  of  extension  with  manipulation 
sometimes  succeeds  in  reducing  this  dislocation.  The 
thigh  is  tirst  flexed  on  the  abdomen,  and  then  the 
head  of  the  bone  is  forcibly  dragged  upwards  and 
outwards  into  its  socket,  the  surgeon  standing  over 
his  patient  and  fixing  the  pelvis  by  placing  his  foot 
on  the  horizontal  ramus  of  the  pelvis. 

Reduction  by  extension  with  pulleys  must  be  con- 
ducted in  the  following 
manner  ;  counter-extension 
is  made  by  a  girtli  or  belt, 
which  is  to  encircle  the 
j)elvis,  and  is  fixed  to  a 
staple  in  the  wall  on  the  pa- 
tient's sound  side.  Another 
girth  is  placed  round  the 
upper  part  of  the  injured 
thigh;  and  passed  under  the 
pelvic  gii'th  to  prevent  it 
slipping.  To  this  is  attached 
the  pulleys,  which  are  fixed 
to  a  staple  in  the  wall  on 
the  same  side  as  the  in- 
jured limb.  Extension  is 
now  made  so  as  to  pull 
the  bone  outwards  and 
upwards,  and  at  the 
same     time     the     ankle    is 

grasped  and  drawn  towards   the  middle   line   of   the 
body. 

Dislocation  011  to  the  pubes. — In  this  dis- 
location the  position  which  the  head  of  the  bone 
assumes  varies  %ery  much.  Generally  it  is  found 
resting  on  the  junction  of  the  horizontal  ramus  of  the 
pubes  with  the  ilium,  but  it  may  be  placed  on  any 
part  of  the  pubes,  even  as  far  inwards  as  to  be  in 
contact  with  its  spine.  Sometimes  it  is  displaced  in 
N— 21 


Fig.  4(5.— Di^-location  of  the 
Femur  ou  to  the  Pubes. 


194  Manual  of  Surgery, 

front  of  the  pubes,  lying  a  little  to  the  inner  side  of 
the  anterior  inferior  spinous  process  of  the  ilium. 

Symptoms. — This  luxation  is,  perhaps,  of  all 
dislocations  of  the  hip,  the  one  most  easy  of  recogni- 
tion, on  account  of  the  fact  that  the  head  of  the  bon« 
is  generally  plainly  to  be  perceived  as  a  rounded 
swelling  just  above  Poupart's  ligament.  There  is 
also  considerable  deformity  about  the  hip,  and  a 
general  appearance  of  flattening,  with  absence  of  the 
prominence  of  the  trochanter.  There  is  slight 
shortening  of  the  limb,  and  the  knee  and  foot 
are  very  considerably  everted,  and  more  or  less 
abducted  fi'om  the  middle  line  of  the  body,  and  the 
knee  cannot  be  approximated  to  the  one  on  the  oppo- 
site side  of  the  body.  There  is  often  great  pain  down 
the  front  and  inner  side  of  the  thigh,  from  stretching 
of  the  anterior  crural  nerve.  A  certain  amount  of 
flexion  and  outward  rotation  is  possible,  but  any 
inward  rotation  or  extension  is  impossible. 

Treatment. — Reduction  by  manipulation  should 
first  be  attempted,  and  wdll  generally  be  found  to 
succeed.  The  patient  is  laid  flat  on  his  back  on  the 
floor,  and  the  thigh  flexed  in  an  abducted  position,  so 
that  the  knee  is  carried  beyond  the  line  of  the  side  of 
the  body.  The  thigh  is  now  circumducted  inwards, 
so  that  the  knee  is  over  the  median  line  of  the  body. 
This  circumduction  inwards  must  not  be  carried  too 
far,  otherwise  the  head  of  the  bone  will  be  forced  past 
the  socket,  and  a  displacement  backwards  be  the 
result.  The  thigh  is  now  rotated  outwards  and 
extended,  so  as  to  bring  the  knee  down  to  the  ground. 
Rotation  inwards  appears  to  succeed  in  some  cases 
equally  as  well  as  rotation  outwards. 

Extension  by  pulleys  must  be  applied  as  follows  : 
the  pelvis  having  been  fixed  by  a  perineal  band 
fastened  to  the  wall  a  little  above  and  behind  the 
line    of  the  body,  extension  is   made  in   a  direction 


iDlSLOCATlONS   OF    THE   pATELLA,  1 95 

downwards  and  outwards.  After  this  has  been  done 
for  some  time,  an  assistant  lifts  the  head  of  the 
bone,  by  means  of  a  towel,  over  the  brim  of  the 
acetabiilnm. 

After  reduction,  in  all  forms  of  dislocation  of  the 
hip,  the  patient  is  to  be  kept  in  bed  on  his  back  with 
his  legs  tied  together  and  the  limb  supported  with 
sand-bags.  At  the  end  of  about  two  weeks  passive 
motion  must  be  commenced  and  continued  daily,  great 
care  being  exercised  to  prevent  a  recurrence  of  the 
displacement.  The  patient  must  not  be  allowed  to 
use  his  leg'  for  some  weeks  longer. 

Dislocation  of  the  patelSa. — The  patella 
may  be  dislocated  outwards,  inwards,  or  edgeways. 

Dislocation  outwards  is  far  the  most  common 
displacement,  and  may  be  complete  or  incomplete. 
It  is  produced  either  by  muscular  contraction,  by  the 
violent  action  of  the  quadriceps  extensor  cruris  (and 
hence  is  said  to  occur  more  frequently  in  knock-kneed 
individuals),  or  by  direct  violence,  that  is,  a  blow  on 
the  inner  edge  of  the  bone. 

Symptoms.— The  leg  is  extended,  or  slightly 
flexed  and  fixed  in  this  position  ;  the  knee  is  flattened 
and  broader  than  natural,  and  a  depression  is  to  be 
felt  in  the  position  the  patella  normally  occupies.  In 
the  complete  dislocation  the  bone  can  be  felt  on  the 
outer  side  of  the  joint ;  in  the  incomplete  form  it 
presents  a  prominent  swelling  on  the  outer  part  of 
the  articular  surface  of  the  femur,  its  internal  border 
being  lodged  in  the  notch,  and  its  external  border 
projecting  prominently  under  the  skin. 

Dislocation  inwards  appears  to  be  always 
produced  by  direct  blows  on  the  outer  edge  of  the 
bone.  Like  the  former  dislocation,  it  may  be  com- 
plete and  incomplete,  and  the  symptoms  are  much 
the  same,  with  the  exception  that  the  patella  is  found 
on  the  inner  instead  of  the  outer  side  of  the  joint. 


196  Manual  of  Surgery. 

Treatuieiit. — The  patient  liaving  been  placed 
under  the  influence  of  an  anaesthetic,  the  thigh  is  to  be 
acutely  flexed  on  the  pelvis,  the  leg  at  the  same  time 
being  extended  on  the  thigh.  The  margin  of  the 
patella  which  is  farthest  from  the  centre  of  the  joint 
is  to  be  forcibly  depressed.  This  will  have  the  eflect 
of  raising  the  other  edge,  which,  being  tilted  over  the 
condyles,  is  immediately  drawn  by  the  action  of  the 
muscles  into  its  natural  position. 

Dislocation  edgeways  (or  vertical  rota- 
tion) of  tlie  patella. — In  this  peculiar  dislocation 
the  patella  undergoes  a  vertical  rotation  around  a 
longitudinal  axis  through  its  own  centre.  In  conse- 
quence of  this  one  border  projects  prominently  under 
the  skin,  and  the  other  is  lodged  in  the  intercondy- 
loid  notch,  its  surfaces  being  directed  inwards  and 
outwards.  It  occasionally  happens  that  a  complete 
rotation  takes  place,  and  the  bone  is  turned  com- 
pletely round,  so  that  the  articular  surface  presents 
anteriorly. 

This  accident  is  generally  produced  by  a  direct 
blow  on  the  edge  of  the  patella  while  the  limb  is  in  a 
semiflexed  position.  It  has  been  said  also  to  occur 
from  violent  muscular  contraction  Avhile  the  leg  is 
twisted,  as  in  jumping  with  the  foot  inverted  or 
everted. 

Symptoms. — The  position  of  the  patella  at  once 
establishes  the  nature  of  this  accident ;  its  prominent 
border  can  be  felt  forming  a  hard,  well-marked  ridge 
under  the  stretched  skin,  with  a  depression  on  either 
side  of  it.  The  limb  is  com])letely  extended,  and  any 
attempt  to  flex  it  is  attended  witli  very  great  pain. 

Treatment. — As  a  rule,  reduction  may  be  accom- 
plished by  suddenly  and  forcibly  bending  the  knee 
while  the  patient  is  under  the  influence  of  an  anaes- 
thetic \  or,  should  this  fail,  the  bone  may  be  induced 
to  undergo  a  retrograde  vertical  rotation  by  pressury 


Dislocations  of  the  Kxee. 


'97 


on  the  prominent  margin  of  the  bone  after  tlie  thigh 
has  been  acutely  flexed  on  the  pelviss  and  in  this 
way  reduction  may  be  effected. 

After  the  reduction  of  any  of  the  dislocations  of 
the  patella  there  will  probably  be  some  swelling  and 
effusion  into  the  joint,  and  the  limb  must  be  kept 
fixed  on  a  splint  and  cold  applied  to  the  part.  Pas- 
sive motion  must  be  commenced  early,  and  the  knee 
supported  for  some  long  period  with  a  knee  cap  or 
bandage,  since  these  disloca- 
tions, having  once  taken 
place,  are  very  liable  to 
recur. 

Dislocation  of  the 
knee  is  a  very  rare  form  of 
injury,  and  is  always  the  re- 
sult of  very  great  violence. 
It  may  occur  in  four  princij)al 
directions  :  forwards,  back- 
wards, inwards,  and  outwards, 
and  any  of  these  dislocations 
may  be  complete  or  incom- 
plete. As  a  rule,  however 
the  antero-posterior  disloca- 
tions are  complete ;  the  lateral 
ones  are  incomplete. 

Causes. — These  injuries 
are  generally  produced  by 
some  violent  strain  or  wrench 
of  the  knee,  as  in  a  person 
jumping  from   a  carriage   in 

rapid  motion,  or  a  fall  from  a  horse,  the  foot  being 
entangled  in  the  stirrup,  so  that  the  patient  is  dragged 
along  the  gi'ound. 

In  the  dislocation  forwards  the  displacement 
is  usually  complete,  and  the  popliteal  surface  at  the 
back  of  the  tibia  rests  against  the  anterior  surface  of 


Fig.  47.— Dislocation    of    the 
Knee  forwards. 


igS  Manual  of  Surgery, 

the  lower  end  of  the  femur.  Often  there  is  a  slight 
lateral  displacement  as  well.  The  condyles  of  the 
femur,  projecting  in  the  ham,  sometimes  compress  or 
lacerate  the  popliteal  vessels. 

Syinptouis. — The  deformity  produced  is  very 
great.  There  is  considerable  shortening ;  there  is  a 
projection  in  front  of  the  knee,  above  which  can 
generally  be  felt  the  patella,  freely  movable,  and  the 
quadriceps  extensor  is  quite  lax  and  loose.  Behind 
tlie  joint  the  condyles  of  the  femur  may  be  recognised 
by  their  rounded  form  on  a  lower  level  than  the  tibia 
in  front.  The  limb  below  the  knee  is  generally  cold 
and  swollen,  and  the  pulsation  of  the  tibial  arteries 
diminished  or  absent.  Occasionally  severe  pain  is 
complained  of  from  pressure  on  the  popliteal  nerve. 

In  the  dislocation  backwards  the  anterior 
surface  of  the  upper  margin  of  the  tibia  rests  against 
the  posterior  surfaces  of  the  two  condyles  of  the 
femur,  and  the  displacement  is  therefore  not  so  great 
as  in  the  forward  dislocation. 

Sj^nptoius. — There  is  shortening  of  the  limb, 
though  not  to  the  same  extent  as  in  the  previous  case, 
and  the  knee  is  generally  semiflexed,  but  may  be  ex- 
tended. The  prominence  of  the  condyles  in  front  is 
well  marked,  and  beneath  them  is  a  transverse  de- 
pression. The  patella  can  be  felt  resting  in  the  groove 
between  the  two  condyles.  The  head  of  the  tibia  is 
to  be  plainly  felt  in  the  ham,  where  it  forms  a  projec- 
tion among  the  muscles  of  the  calf. 

In  the  incomplete  form  of  these  antero-posterior 
dislocations  the  symptoms  are  the  same  as  in  the  com- 
plete form,  but  are  less  marked.  As  a  rule,  in  the 
incomplete  form  the  popliteal  vessels  and  nerve  escape 
injury. 

Treatinciit.— The  reduction  of  these  disloca- 
tions is  generally  easy,  on  account  of  the  amount  of 
laceration  of    surrounding    structures  which    usually 


Dislocations  of  the  Knee.  199 

accompanies  the  injury.  The  patient  is  to  be  laid  on 
his  back  and  steady  extension  and  counter-extension 
employed,  the  surgeon  at  the  same  time  endeavouring, 
by  direct  pressure  on  the  displaced  head  of  the  tibia, 
to  push  it  back  again  into  its  proper  position.  After 
reduction,  the  limb  is  to  be  maintained  on  a  splint  for 
two  or  three  weeks,  and  cold  lotions  or  ice  applied. 
At  the  end  of  this  time  passive  motion  should  be 
commenced  and  employed  carefully  and  cautiously. 
It  is  advisable  that  the  patient  should  wear  a  knee 
cap  for  some  time,  inasmuch  as,  the  ligaments  having 
been  extensively  torn,  a  recurrence  is  likely  to  result 
unless  some  artificial  means  of  support  is  employed. 

If  the  popliteal  artery  has  been  compressed  by 
the  displaced  bone,  the  circulation  in  the  tibial  vessels 
will  probably  return  after  reduction  has  been  eflfected. 
If,  on  the  other  hand,  it  has  been  lacerated,  gangrene 
will  probably  supervene,  rendering  amputation  neces- 
sary. 

L<ateral  dislocations  of  the  kiiee  are  more 
common  than  the  antero-posterior  dislocations,  and  are 
generally  incomplete.  The  outer  tuberosity  of  the 
tibia  being  displaced  on  to  the  inner  condyle  of  the 
femur ;  or  the  inner  tuberosity  on  to  the  outer  con- 
dyle, according  as  the  dislocation  is  inwards  or  out- 
wards. 

Symptoms. — The  signs  of  this  injury  are  well 
marked,  and  the  deformity  of  the  joint  at  once  in- 
dicates the  nature  of  the  displacement.  The  promi- 
nence of  the  tibia  on  one  side,  with  a  depression  above, 
and  the  condyle  of  the  femur  on  the  other,  with  a 
depression  below,  at  once  indicate  the  nature  of  the 
lesion.  The  limb  is  slightly  flexed,  and  there  is  a 
sulcus  in  the  situation  of  the  ligamentum  patellae. 
There  is  no  shortening. 

Treatment* — Reduction  is  easy,  and  may  be 
efiected  by  simple  extension;  the  surgeon  at  the  same 


200  Manual  of  Surgery. 

time  gently  moving  the  limb  from  side  to  side,  or  else 
slightly  rotating  it.  After  reduction,  the  same  treat- 
ment must  be  adopted  as  in  the  antero-posterioi 
dislocation. 

I>i<i>locatioii  of  the  semilunar  fibro-carti- 
1ag:es. — These  cartilages  may  be  displaced  in  two 
directions,  either  inwards,  towards  the  spine  of  the 
tibia,  or  outwards,  so  that  they  project  beyond  the 
margin  of  the  tibia.  In  the  first  variety  the  circum- 
ference of  the  cartilage  is  torn  away  from  the  capsule 
of  the  joint  and  is  turned  inwards,  so  as  to  occupy  the 
intercondyloid  notch.  In  the  second  variety  the 
cartilage  is  displaced  away  from  the  centre  of  the  joint, 
so  as  to  project  beyond  the  articular  surface  of  the 
tibia.  There  appears  to  be  some  difference  of  opinion 
as  to  whether  the  internal  or  external  cartilage  is 
most  frequently  displaced.  The  accident  is  generally 
caused  by  some  sudden  twist  of  the  leg  or  foot  while 
the  knee  is  flexed.  Thus  a  patient,  while  walking, 
may  strike  his  toe  against  a  stone  or  some  inequality 
in  the  ground,  and  by  this  means  displace  one  of  the 
fibro-cartilages  of  his  knee.      {See  page  256.) 

Syan|>toGns. — The  patient  is  suddenly  seized  with 
an  acute  and  sickening  pain  in  the  knee,  often  so 
severe  as  to  cause  him  to  fall.  The  limb  is  semi- 
flexed, and  he  is  unable  to  extend  it,  any  effort  to  do 
so  being  attended  with  increased  paiii.  If  the  carti- 
lage has  been  displaced  away  from  the  spine  of  the 
tibia,  it  may  be  felt  projecting  under  the  skin ;  but  if 
it  has  been  displaced  inwards,  it  will  not  probably  be 
felt,  though  there  may  be  a  projection  on  one  or  other 
side  of  the  ligamentum  patellae,  and  a  depression  may 
be  felt  between  the  head  of  the  tibia  and  the  condyle 
of  the  femur.  The  injury  is  usually  followed  by  rapid 
effusion  into  the  joint. 

Treatment. — Reduction  may  usually  be  effected 
by  forcible  flexion  of  the  knee  to  its  fullest   extent, 


Dislocations  of  the  An'kle.  20 f 

and  then,  when  the  patient's  attention  is  directed 
elsewhere,  so  that  tlie  muscles  are  off  their  guard, 
suddenly  extending  the  leg  on  the  thigh.  After  re- 
duction the  knee  must  be  kept  quiet  on  a  splint,  and 
the  synovitis  treated  by  cold.  The  patient  should  be 
instructed  always  to  wear  a  knee  cap,  for  the  accident 
having  once  taken  place  is  very  liable  to  recur. 

Dislocation  of  the  head  of  the  iibula, 
occasionally,  though  rarely,  takes  place.  It  may  be 
dislocated  forwards  or  backwards.  When  the  bone  is 
dislocated  forwards  its  head  is  thrown  on  to  the  an- 
terior surface  of  the  outer  tuberosity  of  the  tibia ;  in 
the  dislocation  backwards  it  rests  against  the  posterior 
surface  of  the  same  bone. 

The  head  of  the  bone  can  be  felt  in  its  new  position, 
and  this,  together  with  the  alteration  in  the  direction 
of  the  axis  of  the  fibula,  at  once  denotes  the  nature  of 
the  injury. 

The  head  of  the  bone  can  generally  be  returned 
to  its  place  by  direct  pressure,  with  the  leg  flexed,  so 
that  the  biceps  is  relaxed.  It  is,  however,  exceedingly 
difficult  to  retain  it  in  position,  and  the  patient  is 
likely  to  recover  with  some  permanent  deformity. 
This  does  not  appear,  however,  to  interfere  much  with 
his  powers  of  progression. 

Dislocation  of  the  ankle. — The  ankle  joint, 
on  account  of  its  great  exposure  to  injury,  is  frequently 
dislocated  ;  the  dislocation,  in  the  majority  of  instances, 
being  complicated  by  fracture.  The  bones  of  the 
tarsus  may  be  displaced  from  the  tibia  and  fibula  in 
five  different  directions,  viz.  outwards,  inwards,  back- 
wards, forwards,  and  upwards. 

Dislocation  outTiards. — This  variety  of  dis- 
location is  by  far  the  most  common,  and  may  be  com- 
plete or  incomplete.  It  is  always  accompanied  by 
fracture  of  the  fibula,  and  when  incom})lete  is  called 
"  Pott's    fracture " ;    when   complete    it  is   sometimes 


202 


Manual  of  Surgery. 


known  as  "  Diipiiytren's  fracture."  The  cause  of  the 
accident  is  almost  always  a  fall  on  the  foot,  in  which 
it  is  twisted  outwards. 

In  Pott's  fractiu'e  the  fibula  is  first  broken, 
usually  about  two  or  three  inches  from  its  lower  ex- 
tremity. The  internal  lateral 
ligament  next  gives  way,  or 
else,  what  is  more  common, 
the  internal  malleolus  is  broken 
off,  and  the  astragalus  be- 
comes partially  displaced  from 
the  articular  surface  of  the 
tibia,  undergoing  a  rotation  on 
its  own  horizontal  axis,  so  that 
the  outer  margin  of  its  superior 
surface  rests  against  the  articu- 
lar surface  of  the  tibia. 

Symptoms.  —  There  is 
great  distortion  of  the  foot, 
which  is  twisted,  so  that  the 
sole  is  everted.  There  is  a 
marked  projection  under  the 
skin,  on  the  inner  side  of  the 
foot,  of  the  internal  malleolus 
or  its  fractured  extremity  ;  and 
on  the  outer  side  of  the  leg, 
above  the  external  malleolus,  is 
a  depression,  where  the  two 
fractured  ends  of  the  fibula 
form  a  retirinor  aiiscle  with  each 
other.  (<See  piige  86.) 
In  the  complete  dislocation  outwards 
(Dupuytren's  fracture)  the  trochlear  surface  of  the 
astragalus  is  completely  disj)laced  to  the  outer  side  of 
the  bones  of  the  leg,  and  at  the  same  time  drawn  up- 
ward.s.  The  fibula  is  fractured.  There  is  in  these 
cases   great    increased    breadth    of   the   ankle,    with 


Fig.  48.— Pott's  Fracture. 


Dislocations  of  the  Ankle.  203 

shortening  of  the  limb.  There  is  prominence  of  the 
internal  malleolus  on  the  inner  side  of  the  leg,  and  this 
process  is  sunken  below  its  natural  level.  The  outer 
malleolus,  which  is  carried  u])wardswith  the  astragalus, 
is  prominent,  and  elevated  above  its  natural  level.  The 
whole  foot  is  rotated  outwards.      {See  page  87.) 

Dislocation  of  the  foot  iiiAvards  is  not  nearly 
so  common  as  dislocation  outwards,  and  requires 
greater  violence  to  produce  it.  It  is  accompanied 
by  fracture  of  the  tibia,  and  often  of  the  fibula 
also,  and  is  caused  by  a  twist  of  the  foot  in  the  oppo- 
site direction  to  that  which  produces  the  outward 
displacement.  The  dislocation  is  incomplete,  and  con- 
sists in  a  rotation  of  the  astragalus  on  an  antero- 
posterior axis,  through  its  own  centre,  in  the  opposite 
direction  to  the  outward  displacement,  so  that  the  sole 
of  the  foot  is  inverted.  The  external  malleolus  projects 
on  the  outer  side  of  the  ankle,  beneath  the  skin,  and 
almost  touches  the  ground.  On  the  inner  side  of  the 
joint  there  is  a  distinct  depression  corresponding  to 
the  fracture  of  the  tibia. 

Treatment. — Reduction  is  generally  easy.  The 
leg  is  to  be  flexed  en  the  thigh  and  the  toes  extended, 
so  as  to  relax  the  muscles  of  the  calf,  and  extension 
made  directly  downwards,  combined  with  slight 
lateral  movement.  If  there  should  be  any  difficulty 
it  may  be  advisable  to  divide  the  tendo  Achillis. 
After  reduction  a  pair  of  side  splints  or  a  junk 
splint  is  generally  all  that  is  necessary  to  maintain 
the  parts  in  their  proper  position.  If  there  is  any 
difficulty  the  special  treatment  as  recommended  by 
Pott  or  Dupuytren  should  be  adopted. 

1.  Pottos  method  consists  in  placing  the  patient 
on  his  injured  side  and  flexing  the  leg  on  the  thigh  ; 
an  ordinary  side  splint,  wdth  the  foot  piece  more 
thickly  padded  than  the  rest,  is  applied  to  the  outer 
side  of  the  leg,  and  a  short  splint  reaching  only  to  tho 


204  Manual  of  Surgery. 

ankle   on  the  inner  side.       Tlie  thickly-padded   foot 
piece  turns  the  foot  inwards. 

2.  Dupuytren^s  method  consists  in  applying  a 
single  side  splint  to  the  inner  side  of  the  leg ;  a  wedge- 
shaped  pad,  with  its  base  downwards,  is  inserted 
between  the  splint  and  the  limb,  its  lower  border 
corresponding  to  the  level  of  the  internal  malleolus. 
The  upper  part  of  the  leg  and  the  foot  are  bandaged 
to  the  splint,  and  the  foot  is  thus  dragged  inwards, 
and  the  eversion  overcome. 

1>islocatioii  backwards  may  be  complete  or 
incomplete.  In  the  former  the  trochlear  surface  of  the 
astragalus  is  thrown  behind  the  lower  end  of  the 
tibia,  which  rests  on  the  neck  of  the  astragalus  and 
scaphoid ;  in  the  latter  the  two  articular  surfaces  do 
not  clear  each  other.  There  is  a  marked  appearance 
of  shortening  of  the  foot.  In  front  of  the  ankle 
is  a  prominent  transverse  ridge,  terminating  in 
an  abrupt  margin.  Behind,  the  heel  is  very  prominent, 
and  the  tendo  Achillis  tense.  The  toes  are  pointed 
downwards. 

Dislocation  forwards  is  not  so  common  as  the 
jn-eceding  dislocation,  and  is  generally  incomplete, 
the  anterior  margin  of  the  tibio-fibular  arch  resting 
on  the  summit  of  the  articular  surface  of  the  astragalus. 
In  these  cases  there  is  an  apparent  elongation  of  the 
foot ;  the  heel  is  less  prominent  than  natural ;  and  the 
space  in  front  of  the  tendo  Achillis  is  filled  by  a 
hard  swelling,  which  may  be  recognised  as  the  lower 
ends  of  the  tibia  and  fibula.  The  tendo  Achillis  is 
lax,  and  is  not  so  prominent  as  in  the  natural  condi- 
tion of  parts. 

Trcatinont. — Dislocation  backwards  can  gener- 
ally be  reduced  with  much  greater  facility  than  the 
forward  dislocation.  They  are  both  to  be  reduced 
in  the  same  way  as  the  lateral  dislocations,  with  or 
without  division  of  the  tendo  Achillis,   according  to 


Dislocation  of  the  Astragalus.  205 

the  necessities  of  the  case.  After  reduction  the  limb 
may  be  put  up  in  a  pair  of  side  splints  and  main 
tained  at  rest  for  two  or  three  weekSj  when  passive 
motion  must  be  commenced. 

Dislocation  iipwai'ds. — This  dislocation  con- 
sists in  a  separation  of  the  tibia  and  fibula  at  theii 
lower  articulation,  and  a  forcing  upwards  of  the 
astragalus  between  the  two  bones.  The  injury 
appears  to  be  always  caused  by  falls  from  a  gi'eat 
height  on  to  the  feet  j  from  this  cause  the  ligaments 
connecting  the  lower  end  of  the  tibia  and  fibula  are 
torn,  and  the  force  being  continued,  the  astragalus  is 
jammed  up  between  them. 

There  is  great  widening  of  the  ankle,  the  malleoli 
stand  out  prominently  and  approach  the  level  of  the 
sole  of  the  foot ;  the  relations  of  the  astragalus  are 
obscured,  and  there  is  an  entire  absence  of  motion  in 
the  ankle  joint. 

Reduction  may  be  accomplished  by  forcible  ex- 
tension, but  in  some  cases  it  has  been  found  impossible 
to  move  the  bone  from  the  position  in  which  it  has 
become  wedged.  Recovery  has,  however,  been  said 
to  have  taken  place  with  a  fairly  serviceable  limb. 

Dislocation  of  the  astragalus. — The  astra 
galus  is  occasionally  displaced  from  all  its  articu- 
lations in  a  direction  forwards,  backwards,  inwards, 
or  outwards ;  or  the  bone  may  undergo  a  very  pecu- 
liar rotation,  either  horizontally,  so  that  the  long  axis 
of  the  bone  is  directed  across  the  joint,  or  it  may  be 
turned  on  its  side,  so  that  the  upper  and  under  sur- 
faces of  the  bone  look  inwards  and  outwards. 

Dislocation  fovAvards  is  the  most  common 
form  of  displacement,  the  bone  being  shot  out  for- 
wards from  its  socket  and  generally  undergoing  a 
partial  rotation,  so  that  the  head  is  inclined  to  one 
or  other  side.  The  dislocation  may  be  complete 
or  incomplete. 


2o6  Manual  of  Surgery. 

The  accident  is  usually  caused  by  a  fall  or  twist 
of  the  foot  while  it  is  extended  on  the  leg.  The 
displaced  bone  forms  a  distinct  tumour  upon  the 
instep  ;  in  front  a  rounded  globular  swelling,  which 
under  the  tense  and  stretched  skin  is  readily  recognised 
as  the  head  of  the  astragalus,  and  behind  this  its 
trochlear  surface  forms  a  projection  in  front  of  the 
tibia,  which  appears  to  be  more  or  less  sunken  and 
shortened. 

Dislocation  backwards. — In  rare  instances 
the  astragalus  may  be  displaced  backwards  from  all  its 
articulations,  the  accident  being  produced  by  twists 
or  strains  of  the  foot  while  in  a  condition  of  flexion. 
In  these  cases  the  most  marked  sign  is  the  presence  of 
a  hard  prominence  just  above  the  heel,  between  the 
tendo  Achillis  and  the  malleoli ;  the  foot  is  appa- 
rently shortened,  and  there  is  a  prominence  of  the 
tibia  in  front. 

I^ateral  dislocations  are,  if  complete,  always 
compound,  and  arc  generally,  but  not  always,  accom- 
panied by  fracture  of  one  or  the  other  malleolus. 
When  the  astragalus  is  thrown  outwards  the  foot  is 
displaced  inwards,  with  great  projection  of  the  ex- 
ternal malleolus ;  when  the  bone  is  displaced  inwards 
the  position  of  the  foot  is  reversed. 

"Version  of  tlie  astragalus.— This  consists  in 
a  rotation  of  the  bone  either  on  a  horizontal  or 
vertical  axis,  and  is  produced  by  violent  strains  or 
twists  of  the  foot,  while  it  is  in  a  position  of  neither 
extreme  flexion  or  extension.  The  diagnosis  of  the 
injury  is  involved  in  considerable  obscurity,  and  is 
generally  to  be  made  by  negative,  rather  than  any 
positive  signs.  Thus  the  history  of  the  accident, 
the  loss  of  motion  at  the  ankle,  and  evident  severe 
injury,  without  any  marked  displacement  or  pro- 
minence of  the  astragalus,  raay  lead  to  a  conjec- 
tural diajrnosis. 


Dislocations  of  the  Foot. 


^o) 


Treat ineiit.— Ill  all  the  various  forms  of  disloca- 
tion of  the  astragalus,  an  attempt  must  be  made  to 
effect  reduction  by  steady  traction  of  the  foot,  with 
the  knee  bent,  and  the  patient  fully  under  the 
influence  of  an  anaesthetic.  If  this  should  fail  the 
tendo  Achillis,  and  any  other  tendon  which  may  be 
felt  on  the  stretch,  should  be  divided,  and  the 
attempt  renewed.  Failing  this  the  limb  must  be 
put  up  in  some  apparatus  and  the  issue  of  the  case 
awaited.  If,  as  often  happens,  sloughing  of  the  tense 
skin  over  the  bone 
takes  place,  the 
astragalus  should 
be  at  once  re- 
moved, by  an  in- 
cision running 
parallel  to  the  ten- 
dons. If  no  slough- 
ing takes  place  the 
patient  may  re- 
cover, with  a  fairly 
useful  limb. 

Siibastraga- 
loid  disloca- 
tion.—This  form 
of  dislocation  con- 
sists in  a  displace- 
ment of  the  rest 
of  the  bones  of  the 

tarsus  from  the  astragalus,  this  bone  remaining  in 
its  proper  position  in  the  tibio-fibular  mortise. 
These  dislocations  are  described  as  taking  place  in 
four  directions  :  backwards,  forwards,  inwards,  and 
outwards.  Of  these,  the  dislocation  backwards  is 
much  the  most  common.  They  are  generally  pro- 
duced l)y  violent  strains  or  twists  of  the  foot,  much  in 
the   sauie    way   as  the  other   dislocations   about   the 


Fig.  49.— Subastragaloid  Dislocation. 


2o8  Manual  of  Surgery. 

astragalus  \  but  in  consequence  of  the  greatest  strain 
being  thrown  on  the  ligaments  which  connect  the 
bone  to  the  scaphoid  and  os  calcis,  they  give  way  first, 
and  the  subastragaloid  dislocation  results,  the  ankle 
joint  remaining  intact. 

In  the  dislocation  backwards  there  is  generally 
some  twisting  of  the  foot  as  well,  so  that  the  bones  of 
the  tarsus  are  disi)laced  outwards  or  inwards,  as  well 
as  backwards,  and  the  head  of  the  astragalus  rests 
either  on  the  outer  or  the  inner  side  of  the  scaphoid, 
where  it  forms  a  globular  swelling,  which  can  readily 
be  recognised  as  the  head  of  the  bone  under  the 
tightly  stretched  skin  over  it.  When  the  bones  of 
the  tarsus  are  dislocated  backwards  and  outwards,  the 
foot  is  everted,  so  that  the  sole  is  directed  more  or 
less  outwards.  The  inner  malleolus  is  prominent  and 
well  marked  under  the  skin,  and  the  outer  malleolus 
buried,  the  os  calcis  projecting  beyond  it.  In  the 
dislocation  backwards  and  inwards  the  position  of  the 
foot  is  reversed ;  it  is  inverted,  the  sole  looking 
inwards,  the  outer  malleolus  is  prominent,  and  tlie 
inner  one  buried.  The  diagnosis  of  this  injury  from 
dislocation  of  the  astragalus  may  be  made  by  ob- 
serving the  unaltered  relation  of  the  malleoli  to  the 
astragalus,  and  by  the  recognition  of  the  fact  that 
there  is  no  shortening  such  as  takes  place  in  complete 
dislocation  of  the  astragalus,  from  approximation  of  the 
OS  calcis  to  the  tibio-fibular  arch,  and  that  a  certain 
amount  of  motion  is  permitted  in  the  ankle  joint. 

Trcatmciit. — There  is  sometimes  the  greatest 
difficulty,  in  these  cases,  in  effecting  reduction ;  this 
has  been  ascribed  to  various  causes  :  to  the  hitching  of 
the  tibial  tendons  round  the  neck  of  the  bone  ;  to  the 
sharp  jjosterior  margin  of  the  under  surface  of  the 
astragalus  beini;  Iodised  in  the  interosseous  oroove  of 
the  OS  calcis ;  to  the  under  surface  of  the  neck  of  the 
astragalus  being  wedged  against  the   shaip  posterior 


Dislocations  of  the  Foot. 


209 


margin  of  the  dorsal  surface  of  the  scaphoid ;  and 
lastly,  to  fracture  of  the  astragalus,  the  broken 
portion  of  bone  preventing  reduction.  The  manner 
in  which  extension  should  be  made  in  these  cases  is 
by  pulling  the  foot  forwards,  at  the  same  time  that  the 
surgeon,  by  placing  his  knee  against  the  front  of  the 
lower  part  of  the 
tibia,  presses  the 
bones  of  the  leg,  and 
with  them  the  astra- 
galus, backwards. 
The  tendo  Achillis, 
or  other  tendons,  if 
tense,  may  require 
division ;  and  failing 
all  efforts  at  reduc- 
tion^ the  same  treat- 
ment must  be  adopted 
in  these  cases  as  was 
recommended  in  those 
of  dislocation  of  the 
astragalus. 

The  other  tarsal 
bones  may  occasion- 
ally     be      displaced 

from  each  other ;  one  of  the  most  common  forms  is 
the  "  medio-tarsal "  dislocation,  where  the  anterior 
tarsal  bones  are  displaced  from  the  calcaneum  and 
astragalus.  Or  single  bones  may  be  dislocated  ;  the 
OS  calcis,  the  scaphoid,  or  the  internal  cuneiform. 
The  cuboid  is  said  to  be  never  displaced  alone.  Ex- 
tension, combined  with  pressure  on  the  prominent 
bone,  will  generally  succeed  in  effecting  reduction. 

Dislocation    of     the    metatarsal    bones    and 
ptialang^es  occasionally  takes  place,  but  they  present 
nothing  of  a  special  character  either  as  regards  their 
nature  or  treatment. 
0—21 


Fi?.  50.— Subastragaloid  Dislocation. 


2IO 


IV.     DISEASES  OF  JOINTS. 

HowAKD  Marsh. 

Synovitis. 

Inflammation  of  the  synovial  membrane  of  the 
joints  may  occur  in  a  variety  of  forms.  Thus,  it  may 
be,  as  to  its  intensity,  acute,  subacute,  or  chronic ;  as 
to  its  products,  serous  or  piinileiit;  while  as  to  its 
cause,  it  may  be  local  when  dependent  on  some 
mechanical  injury  or  over-exertion;  or  general  (or, 
as  it  is  vaguely  termed  constitutional)  when  due  to 
struma,  rheumatism,  pyaemia,  etc.  Although  acute 
and  chronic  synovitis  merge  insensibly  into  each  other, 
through  the  various  grades  of  the  subacute  form,  they 
yet,  when  typical  examples  are  selected,  present  a 
strong  contrast,  alike  in  respect  to  their  morbid 
anatomy,  their  symptoms,  and  their  results. 

Acute  synovitis. — For  the  purposes  of  descrip- 
tion it  will  be  convenient  to  select  an  instance  in  which 
the  affection  has  been  produced  by  local  injury  such  as 
a  severe  wrench.  The  changes  that  take  place  are  in  all 
respects  analogous  to  those  met  with  in  inflammation  of 
any  of  the  connective  tissues.  The  membrane  becomes 
vividly  injected  with  blood,  so  that  its  surface  presents 
a  bright  red  appearance,  involving  especially  the 
various  folds  and  processes,  whose  colour  forms  a 
striking  contrast  with  the  pearly  wliiteness  of  the  arti- 
cular cartilage ;  while  here  and  there  are  to  be  seen 
minute  petechial  specks,  or  larger  extravasations  of 
blood  which  has  escaped  from  over-distended  vessels. 
Becoming  ra}>idly  loaded  with  exudation  products,  the 
membrane  is  rendered  velvety  and  succulent,  and  so 
swollen  that  it  overlaps  and  obscures  the  borders  of 


Synovitis.  211 

the  arfcicnlar  cartilage,  and  lies  closely  packed  iii  all 
the  recesses  of  the  joint.  At  the  same  time,  the  syno- 
vial fluid  rapidly  increases  in  quantity,  and  becomes 
charged  with  inflammatory  products,  so  that  the 
articular  cavity  becomes  distended.  The  fluid  is  at  first 
clear,  but  is  afterwards  mixed  with  leucocytes  and  flakes 
of  fibrine  which  give  it  a  cloudy  appearance  ;  and 
commonly  also  with  a  small  admixture  of  extravasated 
blood.  Having  advanced  to  this  stage,  when  all  its 
characteristic  features  as  an  acute  inflammation  have 
been  developed,  synovitis,  under  the  influence  of 
treatment,  may  subside,  and  undergo  resolution ;  cell 
i:)roliferation  ceases,  exudation  products  are  absorbed, 
the  blood-vessels  regain  their  normal  calibre,  and  the 
membrane  recovers  its  natural  appearance.  In  other 
cases,  however,  which  from  the  first  are  more  severe, 
or  in  wliich  appropriate  treatment  is  not  brought 
to  bear,  the  synovial  fluid  is  rendered  turbid  and 
milky  by  cell  exudation,  and  is  soon  converted  into 
completely  formed  pus.  Should  pus  thus  resulting  be 
evacuated  early,  under  safeguards  against  septic  infec- 
tion, repair  may  occur,  and  the  membrane  gradually 
return,  in  part  or  altogether,  to  its  normal  conditioiL 
In  many  instances,  however,  an  acute  purulent 
synovitis  passes  on  to  destructive  changes,  involving 
the  membrane  itself,  the  ligaments,  and  articular 
cartilages,  and  even  to  some  extent  the  ends  of  the 
bones  forming  the  joint,  so  that  a  general  arthritis  is 
established  (page  235). 

In  suhaeute  synovitis,  changes  similar  to  those 
described  as  occurring  in  the  early  stage  of  the  acute 
form  are  met  with.  They  are,  however,  less  marked, 
and  of  lower  intensity. 

In  chronic  synovitis,  whether  («)  primary  and 
induced  by  some  local  cause  too  mild  in  its  action  to 
excite  acute  inflammation,  or  {h)  remaining  after  acute 
inflammation  has  subsided,  the  synovial  membrane  is 


212  Manual  of  Surgery. 

unduly  vascular  (often  rather  from  venous  congestion 
than  from  active  arterial  injection,  such  as  is  present  in 
the  acute  form),  swollen,  and  succulent,  and  loaded  with 
exudation  products,  which,  as  the  case  proceeds,  may 
either  undergo  development  into  fibrous  tissue,  so 
that  the  membrane  becomes  thickened  and  indurated, 
or  pass  into  a  state  of  fatty  or  "  pulpy  "  degeneration. 
The  amount  of  fluid  in  the  articular  cavity  may 
be  but  little  increased  ;  but  generally  it  is  in  con- 
siderable excess,  so  that  the  synovial  membrane 
is  distended.  The  fluid  is  largely  diluted  with  serum, 
and  often  highly  albuminous,  but  as  it  contains  few 
exudation  cells,  or  flakes  of  fibrine,  it  is  either  only 
slightly  opalescent,  or  remains  quite  clear.  Although 
often  prolonged  over  considerable  periods,  chronic 
synovitis  usually  at  length  undergoes  resolution,  and 
the  changes  above  described  are  slowly  repaired ;  fluid 
is  absorbed,  swelling  subsides,  and  the  tissues  return 
to  their  normal  degree  of  vascularity. 

The  symptoms  of  acute  synovitis  are  pain,  of  a 
tense,  bursting,  or  burning  character,  worse  at  night, 
and  aggravated  by  the  slightest  movement  of  the 
joint,  but  generally  not  associated  with  those  spas- 
modic startings  of  the  limb  which  occur  when  the 
deeper  structures  are  afiected  ;  swelling,  which,  as 
it  is  due  mainly  to  effusion  into,  and  as  it  takes 
the  shape  of,  the  synovial  membrane,  is  very  charac- 
teristic ;  in  very  acute  cases  swelling  is  due  in 
part  also  to  effusion  into  the  soft  structures  around 
the  joint ;  heat  detected  when  the  hand  is  lightly 
placed  on  the  surface,  tenderness  on  pressure,  and  in 
severe  cases,  a  faint  surface  blush.  The  joint  is  somewhat 
flexed,  and  is  kept  in  the  position  of  greatest  ease,  so 
that  the  capsule  and  ligamentous  structures  are  relaxed. 
Muscular  atroi)hy,  detected  on  measurement,  is 
generally  present  early  ul  the  case,  and  sometimes  is 
well   marked    even   in   a   few   days.     These   various 


Synovitis,  213 

symptoms,  after  persisting  for  a  time,  may  gradually 
subside,  and  recovery  may  take  place,  the  usual 
result  when  appropriate  treatment  has  been  adopted. 
The  affection,  however^  is  very  apt  to  be  prolonged 
into  the  chronic  stage. 

Treatment. — The.  fii'st  step  in  the  treatment  of 
acute  synovitis  must  always  consist  in  placing  the 
articulation  at  complete  rest.  This,  in  the  joints 
of  the  upper  extremity,  is  effected  by  means  of 
well-titting  splints ;  while,  when  the  joints  of  the 
lower  extremity  are  involved,  not  only  must  splints 
be  used,  but  the  patient  must  be  confined  to  the 
horizontal  posture.  The  position  of  the  joint  is  a 
matter  of  great  importance.  It  must  be  borne  in  mind 
that  the  attack  may,  through  the  formation  of  adhe- 
sions, leave  the  articulation  fixed  ;  and  also  that,  as  the 
result  of  softening  of  the  ligaments,  and  reflex  spasm  of 
some  of  the  surrounding  muscles,  there  is  a  marked  ten- 
dency, especially  in  the  hip  and  knee,  to  the  production 
of  defoiTuity.  The  joint  must,  therefore,  be  very  gently 
brought  into  a  position  in  which,  should  it  be  left  stiff, 
it  may  still  be  useful.  To  effect  this,  and  while  splints 
are  being  applied,  an  ansesthetic  may,  particularly  in 
children,  be  used  with  advantage,  both  to  produce 
muscular  relaxation  and  to  save  pain.  Subsequently 
care  must  be  taken  that  no  deformity  is  allowed  to 
occur.  Other  means  to  be  adopted  vary  with  the 
case.  At  the  present  day  leeches  are  seldom  em- 
ployed, nor  are  they  often  required ;  yet  when  the  in- 
flammatory process  is  very  acute,  and  sudden  in  its 
onset  in  strong  adults,  the  application  of  eight  or  ten 
leeches  has  a  very  markedly  beneficial  result.  Much 
relief  also  is  obtained  by  cold  evaporating  lotions,  tlie 
application  of  an  ice  bag,  or  by  irrigation  with  iced 
water.  Should  the  synovial  cavity  become  rapidly 
distended,  the  fluid  may  be  drawn  off  with  the 
aspirator,    the    utmost    care     being   taken    to    avoid 


214  Manual  of  Surgery, 

the  entrance  of  septic  matter.  The  removal  even 
of  three  or  four  drachms  from  the  knee  joint 
will  often  give  great  and  permanent  relief.  Should 
the  case  be  seen  at  its  very  commencement,  or 
in  the  first  few  hours  after  the  attack  has  set  in,  the 
inflammatory  process  may  sometimes  be  checked  by 
the  application  of  a  Martin's  indiarubber  bandage, 
which  should,  however,  not  be  put  on  tightly.  Tliis 
method  is  appropriate  in  instances  in  which  synovitis 
has  been  produced  by  a  sprain,  or  wrench,  particularly 
in  such  joints  as  the  ankle  and  the  elbow. 

Adequately  treated,  acute  synovitis  usually  subsides 
in  the  course  of  from  three  to  eight  or  ten  days,  and  re- 
covery gradually  takes  place.  In  some  instances,  how- 
ever, the  affection  runs  on  to  suppuration  ;  a  result 
indicated  by  an  increase  of  pain  and  swelling,  the 
appearance  of  a  distinct  blusli  on  the  surface,  and  the 
presence  of  oedema  of  the  soft  parts  around  the  joint ; 
by  rise  of  temperature  to  101°  to  104°,  often  by  the  oc- 
currence of  a  rigor ;  and  by  an  increase  of  the  symptoms 
of  general  illness,  the  patient  being  restless,  and  unable 
to  sleep  or  take  food,  and  showing  rapid  loss  of  flesh  and 
strength.  The  treatment  necessary  under  these  circum- 
stances is  that  laid  down  for  acute  arthritis  (page  237). 

Subacute  and  chronic  synovitis. — As  in  the  acute 
foim,  the  joint  must  be  kept  at  complete  rest. 
Small  'blisters  are  often  useful.  They  should  be 
applied  in  a  series  of  three  or  four ;  one  healing 
before  the  next  is  put  on.  In  tedious  cases  the  blis- 
tering may  be  continued  for  three  or  four  weeks, 
or  may  be  superseded  in  adults  by  the  application  of 
the  benzoline  cautery.  If  the  joint  still  contains  fluid, 
or  if  thickening  of.  the  synovial  membrane  remains, 
uniform  pressure  by  means  of  the  indiarubber  bandage, 
carefully  adjusted  twice  or  three  times  a  day,  should 
be  used.  Under  this  application  swelling  will  often 
completely  disappear  in  the  course  of  a  very  few  days. 


Rheumatic  Synovitis.  215 

Should  this  plan  fail,  the  joint  may  be  covered  with 
the  v.nguentum  hydrargyri  or  the  unguentum  hy- 
drargyri  compositum  spread  on  lint,  and  over  this  the 
elastic  bandage  may  be  adjusted.  Rest  must  be  main- 
tained as  long  as  there  is  heat  or  pain  in  the  joint ;  or 
while  either  of  these  symptoms  or  any  increase  of 
stiffness  is  produced  by  tentative  exercise.  Later, 
the  joint  may  be  douched  with  hot  salt  water  and 
rubbed  with  stimulating  liniments,  and  passive  move- 
ments (provided  they  do  not  produce  swelling,  heat, 
or  stiffness,  that  does  not  quickly  subside)  may 
be  used.  In  some  instances  the  joint  remains  dis- 
tended with  a  large  quantity  of  fluid,  constituting  one 
of  the  forms  of  hydrops  articuli.  The  treatment  of 
this  condition  is  described  at  page  233, 

Rlieuuiatic  synovitis. — The  morbid  anatomy 
of  rheumatic  synovitis  corresponds  closely  with  that  of 
simple  synovitis  of  a  like  grade  of  severity.  The  in- 
flammatory process,  however,  often  extends  more  widely, 
and  involves  the  subsynovial  and  periarticular  tissues. 
The  cartilages,  in  severe  cases,  are  swollen  or  even  eroded, 
and  the  ligaments  are  inflamed  and  softened.  Suppu 
ration,  though  it  is  very  rare,  does  occasionally  take 
place.  The  characters  of  the  synovial  fluid  vary  with 
the  intensity  of  the  case.  Generally,  it  resembles 
that  of  simple  synovitis,  except  that  it  is  more  rich  in 
fibrine.  Rheumatic  synovitis  usually  ends  in  reso- 
lution in  the  course  of  from  three  or  four  days  to  a 
fortnight.  Not  rarely,  however,  when  inflammation 
has  extended  to  the  ligaments  and  periarticular  tissues 
much  stiffness  may  remain ;  or  even  a  tiTie  fibrous 
ankylosis  may  take  place,  rendering  the  joint  perma- 
nently fixed.  In  the  subacute  and  chronic  forms  of 
the  disease  the  tendency  is  towards  the  organisation 
of  the  inflammatory  products,  and  it  is  to  the  con- 
traction of  this  newly-formed  fibrous  tissue  in  the 
thickened   capsular  and  other  ligaments,  and   in  the 


2i6  Manual  of  Surgery. 

periarticular  tissues,  that  the  stiffness  of  the  joint  so 
frequently  met  with  is  due. 

Sym])toins. — Acute  articular  rheumatism  is  cha- 
racterised mainly  by  the  suddenness  of  its  onset 
and  the  severity  of  the  local  symptoms  The  joint 
becomes  rapidly  swollen  from  effusion  into  the  syno- 
A'ial  cavity  and  perisynovial  tissues.  The  surface 
temperature  is  raised  to  100°  or  104°;  the  skin  over 
the  joint  is  exquisitely  sensitive,  and  often  presents 
a  distinct  Hush,  and  movement  is  extremely  painful. 
Tliere  is,  however,  in  the  condition  of  the  joint  itself, 
nothing  conclusive  as  to  the  nature  of  the  case. 

Diagnosis  turns  on  collateral  circumstances  :  the 
absence  of  injury;  the  sudden  development  of  the  affec- 
tion after  a  chill ;  the  history  of  previous  attacks  of  a 
similar  character ;  the  presence  of  acid  sweats ;  the 
coincident  occurrence  of  rheumatism  in  other  parts  : 
while  should  any  doubt  at  first  exist,  this  is  often  soon 
cleared  up  by  the  appearance  of  the  disease  in  some 
other  joint. 

Acute  rheumatism  differs  from  acute  gout  in  the 
fact  that  it  may  occur  at  any  age  after  early  infancy, 
whereas  gout  is  most  common  between  forty  and  sixty  ; 
that  in  gout  the  symptoms,  especially  the  pain,  are  more 
inteiTnittent  or  paroxysmal,  often  entirely  disappearing 
during  the  day,  and  retiirning  with  agonising  intensity 
during  the  night ;  in  gout,  too,  the  joint  is  much  more 
red  and  sensitive,  and  the  pain  much  more  violent. 
In  gout  the  general  health  is  little  disturbed,  and  the 
pulse  and  temperature  are  but  little  above  the  normal. 
In  the  majority  of  instances  the  first  attack  of  gout 
affects  the  great  toe,  while  in  subsequent  attacks  the 
history  that  the  great  toe  joint  has  been  involved  may 
be  taken  as  a  strong  presumption  as  to  the  gouty 
aature  of  the  affection.  The  presence  of  deposits  of 
urate  of  soda  either  in  the  ears  or  the  finger  joints  will 
also  be  highly  important  evidence  of  irout.  while  the 


Rheumatic  Synovitis.  217 

examination  of  the  blood  for  uric  acid  would,  if  it 
were  thought  advisable,  still  further  assist  in  diagnosis. 

Treatment. — Much  of  the  suffering  attending 
acute  rheumatism  is  due  to  the  dragging  weight  of  the 
limb,  and  great  relief  is  often  afforded  by  supporting 
the  joint  upon  a  splint.  A  splint  is  also  advisable,  since 
it  keeps  the  joint  in  a  satisfactory  position  and  pre- 
vents deformity  (to  which  there  is  sometimes  a  strong 
tendency  in  cases  in  which  the  ligaments  are  inflamed 
and  softened),  which  might  subsequently  lead  to  serious 
results.  The  joint  should  be  covered  with  lint  soaked 
in  belladonna  liniment  or  lead  and  opium  lotion  ;  or  be 
sprinkled  over  with  a  solution  of  atropine  and  morphia, 
*nd  wrapped  in  cotton  wool.  The  plan  of  freely 
blistering  the  joint,  as  advised  by  Dr.  Herbert  Davies, 
sometimes  gives  speedy  relief.  Experience,  no  doubt, 
shows  that  the  aspiration  of  a  joint  that  has  suddenly 
become  tensely  distended  gives  great  relief,  but  the 
operation  cannot  be  said  to  be  free  from  risk,  and 
cannot  be  reijarded  as  desirable  in  these  cases. 
Should  the  extremely  rare  event  of  suppuration 
occur  the  case  must  be  treated  as  described  at 
page  237.  In  severe  attacks  affecting  the  knee  and 
the  wrist,  there  is  a  formidable  tendency,  as  the 
result  of  softenincr  of  the  ligaments  and  reflex 
muscular  spasm,  to  displacement  and  distortion. 
Should  this  result  be  threatened,  no  time  should 
be  lost  in  supporting  the  joint  by  the  application  of 
efficient  splints. 

Chronic,  rheumatic  synovitis. — In  this  con- 
dition (often  left  after  the  acute  form  has  subsided) 
the  affected  joint  remains  enlarged,  tender  on  pressure, 
painful  on  movement  or  when  the  part  is  warm  in 
bed,  and  so  stiff  and  weak  that  the  patient  cannot  lift 
any  object,  or  bear  any  weight  on  the  limb.  Usually 
several  joints  are  affected  ;  the  knee,  shoulder,  and 
the  small  joints  of  the  fingers  are  most  often,  the  liip, 


2i8  Maxual  of  Surgery. 

perhaps,  the  most  seldom  attacked.  The  afiection  is 
rerj  erratic,  often  changing  from  joint  to  joint,  and 
varying  in  its  severity  with  the  weather,  temperature, 
degree  of  damp,  etc.,  and  especially  with  the  patient's 
general  health.  The  disease  may  last  for  many  weeks  or 
even  months,  while  in  some  cases  the  joints  are  left  per- 
manently weak,  stiff,  and  painfuL  In  some  cases  the 
disease  assumes,  from  the  first,  a  chronic  and  insidious 
form,  attended  with  pain,  weakness,  and  stiffness,  and 
with  creaking  and  grating ;  and  goes  on  to  changes  in- 
volving the  cartilages  and  articular  ends  of  the  bones, 
the  former  becoming  fibrillated  and  worn  away ;  the 
latter  eburnated  and  "lipped  "  at  their  articular  mar- 
gins. In  a  thii'd  group  so  much  effusion  occurs  into 
the  synovial  cavity  as  to  constitute  one  of  the  varie- 
ties of  hydrops  articuli  (page  232). 

Treatment. — Rheumatic  subjects  should  wear 
flannel  underclothing  in  warm  as  w^ell  as  in  cold 
weather,  so  that  a  uniform  temperature  of  the  surface 
is  maintained,  and  any  joint  that  is  affected  should  be 
enclosed  with  a  woollen  knee  cap  or  similar  covering. 
Though  fatigue  must  be  avoided,  the  patient  should  be 
advised  to  keep  the  joint  in  gentle  exercise  (except 
during  sharp  attacks),  for  a  fixed  condition  of  the  articu- 
lation certainly  increases  the  tendency  to  stiffness.  It  is 
a  good  plan  to  direct  the  patient  to  practise  the  carrying 
of  the  limb  through  its  full  range  of  movement,  or  to 
have  gentle  passive  movement  regularly  performed. 
Local  treatment  consists  in  douching  and  bathing 
the  joint  with  the  hottest  water  that  can  be  borne 
without  pain,  and  in  the  use  of  the  hot  vapour  bath 
and  of  shampooing.  For  the  management  of  cases  m 
which  the  joint  is  distended  with  fluid  see  page  233, 

When  joints  are  the  seat  of  long-standing  rheu- 
matism, relief  is  often  obtained  by  strapping  with  soap 
plaister  or  the  emplastrum  ammoniaci  cum  hydrargyro. 
The  continuous  electric  current,  in  a  mild  form,  is 


Gout.  219 

80Juetimes  very  useful,  both  in  the  relief  of  pain  and 
in  arresting  atrophy  of  the  surrounding  muscles. 

General  treatment  comprises  the  use  of  alkalies  (bi- 
carbonate or  citrate  of  potash),  with  bark  or  some 
bitter  tonic,  if  the  patient  is  in  weak  health.  In 
anaemic  cases,  quinine  and  iron  should  be  given. 

Potassium  iodide,  in  small  doses,  combined  with 
an  alkali,  is  often  beneficial.  Free  excretion,  both  by 
the  bowels  and  kidneys,  should  be  promoted  by  the  use 
of  afierient  mineral  waters  (of  which,  probably,  the 
Huny^di  Janos  is  the  best),  and  of  diluent  drinks.  A 
damj)  climate  should  be  avoided.  Great  benefit  is 
obtained  from  residence  at  such  of  the  health  resorts 
as  are  placed  at  a  considerable  level  above  the  sea, 
and  at  which  hot  baths,  douching,  and  shampooing, 
can  be  obtained.  The  most  suitable  are  Buxton  and 
Harrogate  in  England  ;  and,  on  the  Continent,  Aix-les- 
Bains,  Baden,  and  Wiklbad. 

<jrOUt. — Gout  is  a  constitutional  affection,  one  of 
the  main  lesions  of  which  consists  of  an  inflammation 
of  the  joints,  associated  ^^•ith  the  deposit  of  urate  of 
soda.  The  morbid  anatomy  of  the  disease,  so  far  as  it 
involves  the  joints,  is  briefly  the  following  : 

During  an  acute  attack  the  synovial  membrane 
presents  the  appearances  met  with  in  simple  acute 
synovitis,  as  to  increased  vascularity  and  swelling ; 
while  the  fluid  is  increased  in  quantity,  and  rendered 
turbid  by  cell  exudation.  The  articular  cartilages  be- 
come inflamed,  and  microscopic  examination  shows 
abundant  cell  proliferation,  and  a  tendency  to  fibrilla- 
tion of  the  matrix ;  while  both  on  the  surface  and  in 
the  substance  of  the  cartilage,  especially  in  the  cen- 
tral or  deeper  parts,  a  white  deposit  of  urate  of  soda 
takes  place. 

In  cases  of  long  standing  the  cartilage  is  eroded  and 
worn  away,  and  the  articular  ends  of  the  bones  are 
more  or  less  exposed.    These,  as  the  disease  advances, 


2  20  Manual  of  Surgery. 

become  invaded  with  the  deposit  of  urate  of  soda, 
and  the  seat  of  chronic  inflammatory  changes.  A 
similar  deposit,  followed  by  inflammation,  progresses 
in  the  synovial  membrane,  ligaments,  and  in  the  peri- 
articular structures.  Ankylosis,  though  it  is  very  rare, 
occasionally  takes  place.  Much  more  commonly,  how- 
ever, loss  of  movement  is  due  to  alteration  in  the  shape 
of  the  articular  ends  of  the  bones,  and  to  degenera- 
tive changes  involving  the  syno^'ial  membrane,  liga- 
ments, and  other  soft  structures,  in  and  around  the 
joint.  Most  pathologists  hold  that  the  phenomena  of 
gout  are  originally  due  to  an  increase  in  the  amount 
of  uric  acid  in  the  blood  ;  and  it  is  believed,  so  far  as 
the  joints  are  concerned,  that  this  substance  is  de- 
posited, in  combination  with  soda,  in  the  form  of  the 
urate,  and,  by  its  presence  in  the  tissues,  induces  the 
inflammatory  outbreaks  observed  in  this  affection. 

Symptoms. — Gout  attacks  the  joints  in  two  main 
forms,  the  acute  and  the  chronic,  connected  with  each 
other  by  numerous  intervening  gi'adations.  In  a 
typical  example  of  the  acute  form,  a  patient  who  has 
gone  to  bed  in  apparently  good  health  is  awoke  with 
sharp  pain  in  the  metatarso-phalangeal  joint  of  the  great 
toe.  He  feels  chilly,  or  even  has  a  distinct  shivering 
fit  succeeded  by  free  perspiration.  Pain,  which  is  of  a 
boring  or  wrenching  character,  increases  till  it  reaches 
an  unbearable  intensity.  The  toe  is  swollen  and  stiff, 
and  the  skin  exquisitely  sensitive  and  bright  red,  and 
marked  with  distended  veins.  The  surface  pits  on 
pressure,  and  oedema  extends  for  some  distance  over 
the  adjacent  part  of  the  foot.  Towards  morning 
swelling  increases,  and  pain  becomes  less  intense ; 
and  the  day  is  passed  in  comparative  ease.  During 
the  following  night,  however,  all  the  symptoms  return, 
with  even  more  than  their  former  severity,  and  the 
patient  is  feverish,  restless,  and  distressed  ;  but  in 
a  few  hours  perspiration    comes  on   and   he  is  able 


Symptoms  of  Gout.  221 

to  sleep  ;  and  on  waking  he  finds  that  the  swelling, 
redness,  and  other  symptoms  have  to  a  great  extent 
disappeared.  These  characteristic  exacerbations  by 
night  and  remissions  during  the  day  continue  for  three 
or  four  days,  and  then  the  afiection  subsides,  and  is 
followed  by  desquamation  of  the  skin,  and  often  by 
very  troublesome  itching.  Suppuration  has  been  met 
with,  but  is  extremely  rare.  The  ball  of  the  great  toe 
is,  in  a  large  proportion  of  instances  of  typical  gout,  the 
first  joint  to  suflfer  ;  but  this  is  not  always  the  case,  and 
either  the  knee,  elbow,  wrist,  or  the  small  finger  joints 
may  be  the  seat  of  the  original  attack.  Frequently, 
as  gout  subsides  in  one  joint,  it  appears  in  the  corre- 
sponding joint  of  the  opposite  limb.  All  the  articula- 
tions, including  those  of  the  fingers  and  toes,  are  liable 
to  be  affected,  but  the  shoulder  and  hip  usually  escape. 
In  weakly  and  anaemic  persons,  especially  in  women, 
gout  occurs  in  a  less  violent  form,  and  all  the  symp- 
toms mentioned  above  are  subacute.  The  affection  is 
often  very  persistent,  and  leaves  the  joints  in  a  very 
weak  and  crippled  condition.  Complete  ankylosis, 
though  rare,  is  occasionally  met  with.  An  attack  of 
gout  may  be  induced  by  a  variety  of  causes ;  by  er- 
roneous diet,  particularly  by  the  free  use  of  malt  liquors 
or  wine,  especially  where  the  different  kinds  are  mixed  ; 
excessive  fatigue,  mental  anxiety  or  excitement,  ex- 
ternal injury,  such  as  a  fall  or  even  a  slight  sprain,  or 
a  surgical  operation ;  I  have  seen  it  follow  vaccination 
performed  on  a  patient  who  was  a  little  over  fifty 
years  of  age.  When  the  acute  merges  into  the  chronic 
form  the  seizures  grow  less  acute  but  more  prolonged, 
and  of  more  frequent  occurrence ;  and  involve  a  larger 
number  of  joints,  which  become  weak,  stiff",  painful,  and 
distorted,  and  not  rarely,  particularly  the  joints  of  the 
hand,  the  seats  of  deposits  of  urate  of  soda  forming 
*  tophi '  or  chalk  stones.  When  these  are  large  they 
often  produce  suppuration,  leading  to  ulceration  of  the 


2  22  Manual  of  Surgery. 

skin  and  the  prolonged  discharge  of  sanious  pus,  loaded 
with  urates  in  the  form  of  chalky  material.  In  some 
instances  several  of  these  abscesses  form  in  the  same 
hand,  and,  though  causing  little  disturbance,  remain 
open  for  many  months.  In  chronic  gout  the  general 
liealth  is  much  impaired,  and  the  patient  becomes  pale, 
thin,  and  cachectic. 

Diagnosis. — As  special  remedies  are  called  for 
it  is  a  matter  cf  great  importance  to  recognise  gout 
without  delay  when  it  attacks  the  joints.  The  fol- 
lowing are  the  main  points  to  take  into  considers/- 
tion.  The  question  whether  the  disease  has  occurred 
in  other  members  of  the  family,  or  whether  the  patient 
has  already  suffered  from  the  disease.  The  patient's 
age.  Gout  is  very  rare  before  puberty,  and  does 
not  usually  occur  before  thirty  or  forty  ;  but  after 
this  period  it  is  common  up  to  very  old  age.  The 
disease  is  more  common  in  men  than  in  women. 
In  women  it  most  commonly  occurs  after  men- 
struation has  ceased.  The  habits  of  the  patient  as  to 
diet  often  suggest  the  probability  of  gout.  Gouty 
persons  are  often  markedly  dyspeptic,  and  unable  to 
digest  either  malt  liquors  or  wine.  The  character  of 
the  attack  itself  must  be  considered.  When  a  joint, 
especially  if  it  be  the  gi-eat  toe  joint  in  a  middle-aged 
or  old  person,  becomes,  apart  from  injury,  suddenly 
during  the  night  extremely  painful  and  tender,  and 
when  the  skin  over  the  joint  is  bright  red  and  oedema- 
tous,  gout  may  be  strongly  suspected.  In  gout  the 
body  temperature  is  but  little  raised,  and  the  patient's 
general  health  but  little  disturbed  ;  while  in  acute 
rheumatism  and  pyemia  (the  affections  which  locally 
present  the  strongest  resemblance  to  gout)  the 
temperature  is  high  and  constitutional  disturbance 
considerable.  In  gout,  also,  remissions  by  day  and 
exacerbations  by  night  are  distinctly  marked.  Gouty 
deposits  of  urate  of  soda  should  be  lookeil  for  in  th«» 


Treatment  of  Gout.  223 

finger  joints,  the  ears,  and  in  any  enlarged  bursae  that 
may  be  present.  For  a  full  list  of  the  minor  signs  of 
srout  the  student  should  consult  Sir  James  Packet's 
valuable  and  graphic  article  in  his  volume  of  "  Clinical 
Lectures  and  Essays.'*'  Chronic  gout  may  usually  be 
recognised  by  the  patient's  history  of  previous  acute 
attacks  involving  the  great  toe  ;  th 3  frequent  presence 
of  uric  acid  in  the  urine,  the  sudden  onset  and  equally 
sudden  cessation  of  the  attack,  the  nocturnal  exacer- 
bations, and  the  presence  of  deposits  of  urate  of  soda 
in  the  situations  already  mentioned.  The  urine  should 
always  be  examined  for  albumen,  which  is  often 
present  in  chronic  gout. 

Treatment — This  must  be  local  and  general. 
The  joint  must  be  supported  in  a  position  favouring 
the  relief  of  congestion.  When  any  joint  of  the 
lower  extremity  is  attacked  the  limb  must  be  kept  in 
the  horizontal  posture ;  the  elbow,  wrist,  or  hand  must 
be  kept  in  a  sling.  Though,  in  so  acute  an  inflam- 
matory process,  leeches  seem  indicated,  all  authorities, 
including  Dr.  Garrod,  oppose  their  use,  on  the  ground 
that  local  depletion  seems  to  favour  the  deposit  of  urate 
of  soda  and  the  production  of  stiffness  or  even  of  anky- 
losis. The  joint  should  be  wrapped  in  a  layer  of  cotton 
wool,  covered  with  oil-silk  ;  or  a  lotion  consisting  of  one 
grain  of  atropine,  eight  of  morphia,  and  two  drachms 
of  spirits  of  wine  in  an  ounce  of  water  may  be  applied 
on  lint  under  oil-silk  ;  or  a  lotion  of  lead  and  opium 
may  be  used  in  a  similar  manner.  General  treatment 
should  commence  with  an  aperient.  Colchicum  exerts 
a  powerful,  often  almost  magical  influence  upon  gout, 
yet  the  drug  so  often,  especially  in  weakly  persons, 
produces  sickness,  purging,  and  general  prostration, 
that  it  must  be  cautiously  given.  It  is  most  eflicacious 
in  the  acute  gout  of  the  strong  and  full-blooded  ;  but  it 
also  often  gives  relief  in  chronic  gout ;  and  some  patients 
who  are  weakly  and  broken  down  in  general  health 


ar24  Manual  of  Surgery. 

not  only  tolerate  the  drug,  but  derive  signal  benefit 
from  its  use.  It  should  therefore  be  prescribed  in  the 
acute  forms  of  gout ;  and  also  cautiously  in  chronic  gout 
should  other  drugs  fail  to  give  relief.  An  alkali,  in 
the  form  of  the  bicarbonate  or  citrate  of  potash,  should 
be  given  to  coiTect  acidity  in  the  urine.  Lithia  de- 
rives its  value  in  gout  from  the  fact  that  urate  of 
lithia  is  a  more  soluble  salt  than  that  of  either  potash 
or  soda.  The  citrate  or  the  carbonate  should  be 
given,  in  doses  of  four  or  five  grains,  in  potash 
water ;  or,  in  combination  with  twenty  grains  of 
citrate  of  potash,  in  a  tumbl  er  of  water  twice  or  three 
times  a  day.  In  chronic  gout  much  benefit  is  obtained 
by  a  course  of  treatment  at  the  health  resorts  men- 
tioned on  page  219.  For  ansemic  patients  bark  or 
quinine  should  be  prescribed,  in  combination  with  the 
directions  already  mentioned. 

S>i>liilis. — Afiections  of  the  joints  are  among 
the  rarest  manifestations  of  syphilis.  Yet  it  is  pro- 
bable that  they  are  more  common  than  has  hitherto 
been  supposed.  They  may  be  met  with  at  any  period, 
both  in  the  secondary  and  tertiary  stages,  and  also  in 
the  inherited  form  of  the  disease.  {See  page  250,  vol.  i.) 

1.  In  the  secondary  stage,  during  the  prevalence 
of  skin  eruptions,  ulcers  of  the  tonsils,  plastic  iritis, 
etc.,  one  or  more  of  the  joints  (most  usually  a  single 
articulation,  and  that  either  the  knee  or  the  elbow) 
may  be  the  seat  of  an  affection  consisting  of  gum- 
matous infiltration  of  the  subsynovial  tissue  and 
eff'usion  into  the  synovial  cavity.  In  these  cases 
thickening  of  the  periarticular  tissues  in  the  form 
of  ill-defined  indurations,  or  sometimes  of  distinct 
nodular  deposits,  may  sometimes  be  detected.  In  their 
general  character,  however,  these  affections  present 
little  to  distinguish  them  from  ordinary  chronic  syno- 
vitis, and  their  true  nature  is  suggested  only  by  tlieir 
origin  apart  from  the  common  causes  of   synovitis, 


Syphilis  of  Joints.  225 

and  the  fact  that  the  subjects  of  them  ha,ve  had,  or 
are  still  suffering  from,  other  forms  of  syphilitic 
disease.  Their  main  features  are  their  persistency, 
and  their  strong  tendency  to  relapse.  Pain,  heat,  and 
stiffness  are  usually  but  little  marked.  A  woman, 
the  subject  of  secondary  syphilis,  was  lately  seen  at 
St.  Bartholomew's  Hospital,  in  whom  synovitis  of  the 
elbow  joint  with  effusion  disappeared  under  the  use 
of  iodide  of  potassium  three  times,  but  at  once  re- 
lapsed as  soon  as  the  iodide  was  discontinued.  Ulti- 
mately, however,  complete  recovery  took  place. 

2.  In  other  instances,  in  the  tertiary  jieriod,  the 
disease  consists  of  an  osteitis  and  periostitis  of  the 
articular  end  of  one  of  the  bones  forming  the  joint, 
leading  to  the  formation  of  node-like  outgrowths 
similar  to  those  met  with  in  other  examples  of  syphi- 
litic osteitis,  and  accompanied  with  gummatous  in 
filtration  of  the  synovial  membrane  and  effusion  into 
the  cavity  of  the  joint. 

3.  In  some  instances,  again,  though  rarely,  the  joint 
is  involved  by  the  breaking  down  of  a  large  gumma 
in  the  subcutaneous  tissue,  and  the  subsequent  ulcera- 
tion attending  the  process.  In  one  case  the  knee 
joint  was  involved  in  the  course  of  syphilitic 
necrosis  of  the  patella.  Some  of  the  most  obstinate 
examples  of  syjihilitic  affections  of  the  joints  are  those 
in  which  the  disease  is  combined  with  chronic  gout, 
rheumatism,  or  osteo-arthritis.  In  infants  syphilis  takes 
its  origin  as  a  subacute  inflammation  involving  the  line 
of  junction  of  the  epiphysis  with  the  shaft.  Here,  as 
the  inflammatory  process  advances,  a  soft  granulation 
tissue  is  formed,  and  ulceration  ensues',  with  the  result 
that  the  epiphysis  often  becomes  detached  from  the 
shaft ;  caries  may  extend  so  as  to  involve  the  bone 
for  some  distance.  In  many  cases  no  matter  forms, 
and  the  joints  themselves  escape ;  but  in  other 
instances    suppuration  occurs,   the   structure    of    the 

p— 21 


2  26  Manual  of  Surgery. 

epiphysis  is  broken  down,  and  the  articular  cavity  is 
involved  in  the  extension  of  the  disease. 

The  diagnosis  of  these  cases  may  be  attended  with 
considerable  difficulty.  A  joint  affection,  however, 
may  well  be  suspected  to  be  syphilitic  when  it  occurs 
apart  from  local  injury  in  a  person  who  gives  no 
history  of  gout  or  rheumatism,  but  who  has  had 
syphilis ;  and  when  ordinary  forms  of  treatment  fail ; 
when  other  syphilitic  lesions  are  jiresent ;  and  when 
the  irregular  thickening  or  nodular  swelling  of  the 
synovial  membrane  and  periarticular  structures  re- 
sembles gummatous  infiltration  of  these  tissues  rather 
than  any  of  the  usual  forms  of  chronic  inflammation. 
In  some  cases  nocturnal  pains,  depending  on  osteitis 
and  periostitis,  are  well  marked. 

Treatment  consists  in  the  use  of  splints  to  maintain 
the  joints  at  rest,  and  the  administration  of  iodide 
of  potassium.  In  obstinate  cases  the  iodide  salt 
should  be  combined  with  the  liquor  hydrargyri  per- 
chloridi,  and  the  joint  should  be  strapped  with  mer- 
curial ointment  and  soap  plaister,  or  a  liniment 
of  the  oleate  of  mercury  may  be  rubbed  in.  The 
disease  is  very  obstinate  and  very  prone  to  relapse ; 
treatment  must,  therefore,  be  persistently  carried  out, 
and  must  include  the  remedies  for  chronic  gout  or 
rheumatism,  when  these  affections  are  present. 

PysBinia,  and  other  acute  specific  diseases. 
— A  general  group  of  cases  of  synovitis  is  formed  by 
those  examples  which  are  developed  in  the  course  of 
pyaemia,  puerperal  and  scarlet  fever,  gonorrhoea,  variola, 
typhoid,  dysentery^  and  some  other  conditions.  In  all 
alike  the  affection  results  from  the  presence  in  the 
blood  of  some  septic  material  derived  from  the  primary 
disease ;  and  in  all  alike  the  process  at  work,  though 
not,  perhaps,  identical  with,  is  analogous  to  and  well 
illustrated  by  that  observed  in  pyaemia.  In  their 
general    clinical    characters   these    various    forms   of 


Pymmia  of  Joints.  227 

synovitis  strongly  resemble  each  other,  though  they 
present  considerable  diflerences  in  their  severity,  the 
structural  changes  to  which  they  give  rise,  and  the 
subsequent  condition  of  the  joints  in  which  they  have 
had  their  seat. 

Pyaiinia. — Tnpy?emia  the  joints  maybe  attacked 
at  any  period  of  the  disease,  which,  it  must  be  remem- 
bered, though  often  acute,  is  sometimes  chronic,  and 
prolonged  over  many  months.  In  acute  cases,  often 
the  first  symptom  of  blood  poisoning  is  synovitis 
of  the  shoulder,  the  knee,  or  some  other  joint,  and  soon 
other  articulations  are  involved.    {8ee  page  148,  vol.  i.) 

In  the  worst  cases  several  joints  are  attacked  in 
rapid  succession.  In  these  instances  the  synovial  mem- 
brane is  acutely  inflamed,  and  the  joint  rapidly  be- 
comes distended  with  flaky  pus,  often  mixed  with  blood, 
giving  it  a  red  or  grumous  appearance  j  and  the  mem- 
brane itself,  the  ligaments,  and  the  cartilages  undergo 
destructive  changes  ;  the  skin  becomes  red,  shining,  and 
perhaps  cedematous,  and  the  joint  within  tiiree  or  four 
days  becomes  completely  disorganised,  the  capsule 
bursts,  and  the  surrounding  soft  parts  become  widely 
involved.  In  less  severe  examples  the  inflammation 
is  subacute,  and  the  synovial  cavity  is  distended  vsdth 
pus,  so  that  its  outline  is  marked  out  by  a  flaccid 
swelling,  in  which  fluctuation  is  extremely  obvious ; 
the  skin,  however,  is  unaltered,  and  there  is  so  little 
heat  or  pain  that  the  patient  makes  no  complaint  of 
the  joint,  the  condition  of  which  may  be  easily  over- 
looked, or  be  only  accidentally  discovered ;  while  on 
post-mortem  examination  little  swelling  or  redness  of 
the  membrane  is  to  be  observed ;  and  the  ligaments 
and  the  cartilage  present  no  obvious  change.  In  some 
cases,  again,  sjTiovitis  is  acute  and  plastic,  and  is 
followed  by  firm  fibrous,  or  bony  ankylosis ;  while  in 
others,  large  readily  fluctuating  collections,  not  in- 
volving the  joint  itself,  form  in  the  periarticular  tissue, 


2  28  Manual  of  Surgery. 

yet  without  redness  or  other  signs  of  acute  inflamma- 
tion. It  is  remarkable  that  in  some  examples  of 
pyremia  the  local  manifestations  are  entirely  confined 
to  the  joints,  w^hile  in  other  instances  the  joints 
entirely  escape. 

Prognosis. — In  cases  in  which  the  patients  survive, 
and  repair  takes  place,  the  efiusion  may  be  slowly 
absorbed,  and  the  joint  may  regain  free  movement. 
In  the  majority  of  instances,  however,  there  is  con- 
siderable stiffness,  often  firm,  fibrous,  or  bony  anchy- 
losis, frequently  associated  with  serious  distortion. 

Treatment. — In  consequence,  in  the  less  acute 
cases,  of  the  large  amount  of  effusion  which  takes 
place,  and  which  is  associated  with  relaxation  of  the 
ligaments,  and,  in  acute  cases,  in  consequence  of  the 
rapid  disorganisation  of  the  joint,  there  is  a  strong 
tendency  to  the  displacement  of  the  articular  ends  of 
the  bones.  This  is  especially  the  case  in  the  knee 
and  wrist.  Moreover,  the  joint  is  frequently  the  seat 
of  excessive  pain,  aggravated  by  movement.  It  is 
essential,  therefore,  that  the  limb  should,  from  the 
first,  be  carefully  supported  on  a  splint.  When  the 
disease  is  acute  and  attended  with  suppuration,  matter 
should  be  at  once  evacuated  under  strict  antiseptic 
precautions,  and  free  drainage  should  be  provided. 
When  effusion  is  more  passive,  and  there  is  no  pain 
or  redness  of  the  skin,  the  fluid  may  be  drawn  off  with 
the  aspirator.  The  removal  of  fluid  is  advisable. 
With  care  the  operation  may  be  safely  conducted, 
while,  if  fluid  is  left,  the  fibrine  remaining  after  its 
moi'e  liquid  parts  have  been  absoi'bed  will  lead  to  the 
formation  of  adhesions  and  the  development  of 
ankylosis. 

In  cases  in  which  joints  have  become  disorganised, 
amputation  may,  should  the  patient  survive,  become 
necessary.  The  operation  must  generally,  however,  be 
delayed  till  the  active  stage  of  septic  infection  has 


GONORRHCEAL  SYNOVITIS.  229 

passed,   and  the   temperature   is   no   longer  high  or 
widely  fluctuating. 

In  scarlet  fever  synovitis  resembles  that  met 
with  in  pyaemia  in  being  sometimes  acute,  and  leading 
to  rapid  disorganisation  of  the  joint,  by  extension  of 
the  inflammation  to  the  deeper  structures,  and  some- 
times subacute  or  chronic ;  in  affecting  one  or  several 
joints  ;  and  in  its  general  course,  and  termination.  The 
treatment  is  the  same  as  that  of  synovitis,  depending 
on  pyaemia.  The  same  may  be  said  of  synovitis  occur- 
ring in  the  piterperal  state.  The  joint  affection 
is  essentially  pyemic  in  its  character.  Often  the 
knee  is  the  only  joint  affected,  and  the  inflammatory 
process  is  throughout  subacute.  The  mischief,  how- 
ever, soon  spreads  to  the  deeper  structures,  is  very 
persistent,  is  accompanied  with  severe  pain,  and  tends 
to  induce  deformity  and  to  terminate  in  fibrous  anky- 
losis. In  some  instances  many  joints  are  involved, 
and  the  case  runs  the  usual  course  of  an  acute 
pysemia. 

OoiiorrSi€Eal  or  urethral  synovitis,  —  It  is 
now  well  known  that  not  only  gonorrhoea,  but  also 
simple  purulent  urethritis,  such  e.g.  as  sometimes  occurs 
after  the  use  of  catheters,  may  give  rise  to  synovitis. 
In  this  affection,  for  which  urethral  synovitis  or 
arthritis  is  a  better  name  than  either  gonorrhccal 
synovitis  or  the  old  term  gonorrhoeal  rheumatism, 
usually  one  joint,  and  that  a  large  one,  is  attacked. 
The  knee  is  most  often  affected,  but  the  hip,  the  ankle, 
and  the  wrist  are  not  rarely  attacked,  while  a  very 
troublesome  form  is  that  which  involves  the  ankle  and 
the  contiguous  tarsal  joints  and  the  fibrous  structures 
in  the  sole,  with  the  result  of  inducing  a  very  aggra- 
vated form  of  flat  foot.  The  disease,  though  sometimes 
acute,  and  passing  on  to  suppuration,  or  even  to  com- 
plete disorganisation  of  the  joint  requiring  amputation, 
is  for  the  most  part  subacute  (often  it  is  very  chronic) 


230  Manual  of  Surgery. 

and  characterised  rather  by  plastic  exudation  than  by 
coj^ious  effusion.  The  ligaments  and  the  periarticular 
structures  are  involved  in  the  inflammatory  process, 
and  the  tendency  to  the  formation  of  new  fibrous 
tissue  is  strongly  marked.  Bony  ankylosis,  though  it 
is  I'are,  may  occur.  The  attack  may  be  ])receded  by 
an  increase  of  the  urethral  discharge.  Often,  how- 
ever, the  amount  of  discharge  is  unaltered  by  the  onset 
of  the  joint  disease  ;  while  sometimes  discharge  is  con- 
siderably diminished.  The  disease,  attended  by  pain, 
heat,  and  moderate  swelling,  often  persists  in  a  form 
much  resembling  subacute  or  chronic  rheumatism,  now 
subsiding,  and  presently  returning  with  increased  in- 
tensity for  many  weeks  or  months,  and  at  length 
leaving  the  joint  permanently  stiif.  It  is  not  rarely 
symmetrical.  In  those  cases  in  which  several  of  the 
larger  joints  are  attacked  {e.g.  both  the  knees  and  both 
the  hips,  or  the  ankles  and  the  knees)  the  patient  may 
be  left  completely  crippled.  Even  the  joints  of  the 
spine  may  be  afiected,  and  cases  are  on  record  in 
which  in  the  course  of  difierent  attacks  every  large 
joint  has  become  fixed.  The  affection  is  very  rare ; 
i.e.  its  jiercentage  among  cases  of  gonorrhoea  is  very 
small.  Sometimes  the  affection  is  ushered  in  by  slight 
fever  and  a  sense  of  chilliness,  or  the  occurrence  of  a 
distinct  rigor.  In  other  instances  the  premonitory 
sym])toms  are  absent,  and  the  first  sign  is  that  one  of 
the  joints  is  hot,  tender,  painful,  and  swollen,  as  in 
subacute  iheumatism.  A  notable  fact  respecting  the 
affection  is  that  in  some  individuals  it  is  repeated  with 
every  attack  of  gonorrhoea.  Urethral  synovitis,  though 
occasionally  met  with,  is  very  rare  in  the  female  sex, 
A  correct  diagnosis  is  very  im])ortant,  and  here,  as  in 
so  many  other  cases,  it  is  readily  made  if  the  mind  of 
the  sui-geon  is  on  the  alert.  In  any  case  in  Avhich 
arthritis,  simulating  subacute  rheumatism,  especially 
when  monarticular,  occurs  in  a  person  who  has  never 


Synovitis  in  Typhoid  Fever,  231 

had  rheumatism,  and  when  the  attack  tends  to  be 
prolonged  and  persistent,  the  question  of  the  presence 
of  urethral  discharge  ought  to  be  inquired  into. 

Treatment  must  be  addressed  :  (a)  To  tlie  arrest 
of  the  urethral  discharge.  (6)  To  the  local  manage- 
ment of  the  joint  attack.  The  treatment  of  the 
uretlu'al  discharge  must  vary  with  the  gonorrhoea! 
or  other  origin  of  the  affection,  the  stage  it  has 
reached,  the  amount  and  character  of  the  urethral 
secretion.  (For  directions  on  these  points  see  Art. 
XXIII.,  vol.  i.)  The  joint  should  be  placed  at  rest. 
When  heat  and  other  symptoms  have  subsided  under 
the  use  of  cold  applications,  a  course  of  small  blisters 
(one  healing  before  the  next  is  applied)  should  be 
f)rescribed,  and  the  joint  may  then  be  covered  with 
mercurial  ointment  spread  on  lint,  and  over  this  an 
elastic  rubber  bandage  may  be  adjusted ;  or  the 
part  may  be  strapped  with  soap  plaister.  Iodide  of 
potassium  is  often  useful  in  five-grain  doses  in  the 
after  stages  of  the  disease.  Iron  tonics  will  be  called 
for  if  the  patient  is  anasmic  and  weakly.  If  he  is 
gouty,  lithia  or  colchicum  should  be  used.  {See  under 
Gout.)  Motion  may  sometimes  be  restored  by  move- 
ment of  the  joint  under  an  anjEsthetic,  followed  by 
daily  passive  movement,  hot  douching,  and  shampooing. 

In  the  course  and  after  the  subsidence  of 
tyi>9aoicl  lever,  and  less  frequently  of  variola, 
one  or  more  of  the  joints  may  be  attacked  either  with 
a  subacute  synovitis  (this  is  the  most  common  form), 
or  with  a  plastic  inflammation  involving  also  the 
ligaments  and  the  cartilages,  or  very  rarely  by  an 
acute  suppurative  arthritis.  The  joint  most  fre- 
quently attacked,  at  least  in  typhoid,  is  the  hip,  but 
other  joints  occasionally  suffer.  There  is  developed 
synovitis,  rapidly  leading  to  effusion,  distension  of 
the  capsule,  and  often  to  spontaneous  dislocation,  an 
occurrence  that  is  sometimes  unfortunately  overlooked 


232  Manual  of  Surgery. 

till  the  patient  is  convalescent  from  his  fever.  The 
plastic  form  of  arthritis  is  usually  subacute  and  at- 
tended with  considerable  pain.  It  leaves  the  joint 
stiff,  or  in  severe  cases  completely  ankylosed,  and  this 
often,  where  treatment  has  not  been  applied,  in  a  very 
inconvenient  position.  Suppurative  arthritis,  happily 
very  rare  in  connection  with  the  exanthemata,  presents 
the  general  features,  and  requires  the  treatment  de- 
scribed at  page  237. 

Hydrops  Articuli. 

Hydi'artlirosis,  hydi*arllirus. — In  this  affec- 
tion, often  vaguely  spoken  of  as  dropsy  of  the 
joints,  the  synovial  cavity  becomes  distended  with 
a  chronic  serous  or  watery  effusion.  The  condition  is 
produced  in  several  ways.  It  may  remain  after  acute 
synovitis  has  subsided  ;  or  it  may  arise  in  the  course  of 
chronic  synovitis,  especially  when  this  is  of  rheumatic 
origin  ;  or  it  may  be  developed  apart  from  any  of  the 
usual  signs  of  inflammation,  in  the  form  apparently  of 
a  mere  passive  exudation,  much  resembling  the  simpler 
forms  of  hydrocele  of  the  tunica  vaginalis.  The 
morbid  anatomy  of  the  first  two  varieties  is  the  same 
as  that  of  clironic  synovitis.  In  the  third  form, 
which,  however,  is  rare,  the  synovial  membrane  is 
anemic  and  pale,  or  presents  a  white  or  yellowish, 
macerated  appearance.  In  cases  of  long  standings  the 
membrane  itself  and  its  subserous  layer  become 
thickened  by  new  fibrous  tissue  ;  and  its  processes  and 
fringes  undergo  hypertrophy,  present  numerous  tufts 
and  pedunculated  growths,  and  often  contain  nodules 
of  cartilage. 

In  some  cases  the  major  part  of  even  a  large 
swelling  of  the  joint  is  due  to  the  close  packing  of 
these  synovial  fringes,  and  the  quantity  of  fluid 
present  is  very  small.  As  time  goes  on  the  ligaments 
become  elonijated,  and  displacement  occurs ;    or    the 


Hydrops  Articuli.  233 

joint  is  loose,  weak,  and  insecure  wlien  weight  is 
thrown  upon  it.  In  many  cases  large  bursal  collec- 
tions are  formed  in  the  neighbourhood  of  the  joint. 
The  fluid  of  hydrops  articuli  (which  may  amount  to 
as  much  as  three  pints  or  even  more)  is  a  thin,  often 
turbid,  form  of  synovia,  containing  in  many  instances 
flakes  and  fibrinous  shreds.  The  aflection  is  most 
common  in  the  knee.  It  may  be  limited  t-o  one  knee 
joint,  but  often  both  are  ultimately  attacked.  It 
occurs  also  in  the  shoulder  and  elbow,  and,  though  very 
rarely,  also  in  the  other  joints.  Often  single,  it  seldom 
involves  more  than  two  joints  in  the  same  patient. 

Syiuptoms. — The  knee  joint,  which  may  be  taken 
as  the  best  example,  is  largely  distended,  cool  and  pain- 
less, but  weak,  and  its  movements  are  embarrassed. 
Fluctuation  is  very  obvious.  The  patella,  unless  dis- 
tension is  too  great,  can  be  pressed  down  so  that  it 
strikes  the  femur.  The  synovial  membrane,  in  old 
cases,  is  thickened ;  and  indurated  folds  and  fringes, 
or  even  masses  of  cartilage,  can  be  felt.  The  bursa 
under  the  semimembranosus  muscle  in  the  ham  is 
often  enlarged,  and  may  extend  for  some  distance  down 
the  calf.  The  patient  cannot  walk  far,  and  finds  going 
upstairs  a  great  diificulty.  The  disease  is  most  com- 
mon in  men  between  thirty  and  sixty,  but  it  may  be 
met  with  in  females,  and  at  any  age  after  puberty. 

Treatment. — In  the  early  stage,  especially  when 
hydrarthrosis  is  of  inflammatory  origin,  the  joint  must 
be  kept  at  complete  rest  by  means  of  firm  leather 
or  other  splints,  cut  away  so  that  there  is  space  for 
blistering.  A  succession  of  blisters,  one  and  a  half  to 
two  and  a  half  inches  square,  should  be  applied  at  in- 
tervals of  four  or  five  days,  or  as  they  severally  heal ; 
or  counter-irritation  may  be  produced,  either  by 
iodine  paint,  or  by  rubbing  in  the  unguentum 
hydrargyri  biniodidi  over  a  space  of  two  or  three 
square   inches.      After   the  blistering  (continued  for 


234  Manual  of  Surgery. 

three  or  four  weeks)  the  joint  should  be  compressed  by 
a  carefully  applied  indiarubber  bandage,  under  which 
may  be  placed  lint  spread  with  mercurial  ointment  or 
with  oleate  of  mercury;  or  the  joint  may  be  aspirated 
and  the  treatment,  by  ela.stic  pressure  be  continued. 
When  all  these  means  fail  (and  it  must  be  confessed 
this  is  often  the  case),  the  method  has  been  recom- 
mended, and  occasionally  practised,  of  removing  part 
of  the  collection  with  a  trocar  and  canula,  and  in- 
jecting the  synovial  cavity  with  a  solution  of  tincture 
of  iodine  in  two  or  three  parts  of  water.  Though  it 
sounds  formidable,  this  proceeding,  carefully  employed, 
seems  to  involve  very  little  danger.  Its  success,  how- 
ever, is  very  doubtful;  for  though  it  produces  con- 
siderable inflammatory  effusion,  similar  to  that 
following  the  injection  of  a  hydrocele,  the  fluid  often 
soon  re-accumulates,  and  the  disease  continues  to 
progress.  As  an  ultimate  step,  provided  the  patient 
is  under  thirty  and  in  sound  general  health,  the 
joint  (antiseptic  precautions  being  strictly  carried  out) 
may  be  opened  by  two  free  lateral  incisions  and  the 
fluid  evacuated  ;  drainage  tubes,  or,  better,  strips  of 
guttapercha  tissue,  should  then  be  introduced,  and 
retained  for  two  or  three  weeks  wliile  shrinking  of  the 
synovial  cavity  is  taking  place.  In  a  case  of  hydrops 
articuli  of  rheumatic  origin,  in  a  man  aged  twenty-six, 
Mr.  Willett,  at  St.  Bartholomew's  Hospital,  opened 
the  knee  joint,  scraped  the  synovial  membrane,  and 
washed  out  the  joLut  with  a  solution  of  chloride  of 
zinc  (ten  grains  to  the  ounce).  The  patient  made  a 
favourable  recovery.  The  temperature  never  rose 
above  102  "2°,  and  was  normal  after  the  sixth  day. 
Six  months  later  the  patient  was  found  to  iiave 
retained  a  very  useful  joint,  free  from  swelling,  and 
possessed  of  considerable  movement. 


Arthritis.  235 

Arthritis. 

Wlien  inflammation  attacks  a  joint,  it  always 
begins  either  in  the  synovial  membrane  or  in  the 
bones.  Neither  the  ligaments  nor  the  cartilage  are 
suljject  to  piimary  inflammation.  The  changes  they 
undergo  are  always  secondary. 

Though,  however,  the  affection  originates  in  the 
synovial  membrane  or  the  bones,  it  usually  soon 
extends  to  the  other  structiu-es,  so  that  all  alike  are 
involved.  This  condition  is  termed  arthiitis.  Arthritis 
has  many  forms.  It  may  be  either  acute  or  chronic, 
traumatic,  infective  (as  in  pyiemia,  gonoiThcea,  etc.,) 
or  diathetic  (as  in  struma,  gout,  rheumatism,  etc.).  Of 
these  varieties,  some  only  will  here  be  noticed,  while 
others,  e.cj.  the  pya3mic,  gonorrhceal,  etc.,  are  described 
elsewhere. 

Syiiiptoins. — Attacked  with  acute  inflammation, 
the  joint  is  placed  in  the  position  of  greatest  ease, 
in  that,  namely,  which  it  habitually  occupies  during 
rest,  and  in  w^hich  the  articular  ends  are  relieved  as 
far  as  possible  from  mutual  pressure,  and  the  liga- 
ments and  the  capsule  are  as  far  as  possible  relaxed. 
The  shoulder  remains  w-ith  the  arm  close  to  the  side ; 
the  elbow  and  knee  are  somewhat  flexed ;  the  wrist  a 
little  dropped ;  tlie  ankle  a  little  extended ;  the  hip, 
in  a  typical  case,  is  flexed,  abducted,  and  rotated 
outwards.  The  local  symptoms  are  those  of  acute 
inflammation,  i.e.  pain,  heat,  swelling,  and  often  some 
redness  of  the  skin.  Pain  is  throbbinij  or  bursting  in 
character,  often  so  intense  that  the  patient  screams 
with  agony  if  the  limb  is  moved,  or  even  if  the  bed  is 
jarred.  Nocturnal  exacerbations  are  severe,  and, 
w^henever  he  attempts  to  sleep,  the  patient  is  disturbed 
by  spasmodic  startings  and  jumpings  of  the  limb,  the 
latter  symptom  indicating  that  the  ai-ticular  ends 
beneath  the  cartilage  are  affected.     Increased  heat  is 


236  Manual  of  Surgery. 

easily  detected,  either  by  the  hand  or  the  surface 
thermometer.  Swelling,  which  is  usually  considerable, 
is  due  mainly  to  fluid  in  the  joint,  but  it  depends  in 
part  on  swelling  of  the  synovial  membrane,  and 
eflfusion  into  the  periarticular  tissues. 

Constitutional  disturbance  is  often  severe,  and  the 
temperature  ranges  from  100°  to  104°.  When  carefully 
treated  from  its  onset,  the  aflfection  may  subside  ;  but 
often  it  advances  to  suppuration.  This  event  is  indi- 
cated by  further  rise  of  temperature,  and  often  by  the 
occurrence  of  rigors,  as  well  as  by  an  increase  of  pain  and 
swelling;  the  integuments  become  red  and  oedematousso 
that  they  pit  on  pressure  ;  soon,  as  the  ligaments  become 
either  softened  or  destroyed,  the  articular  ends  of  the 
bones  tend  to  undergo  displacement ;  grating  is  often 
detected,  and  the  patient  loses  sleep  and  appetite,  be- 
comes flushed  and  emaciated,  and  has  copious  perspira- 
tions. In  some  cases  the  quantity  of  matter  formed  is 
not  great ;  in  others  matter  rapidly  increases,  and  unless 
evacuated,  bursts  through  the  distended  and  softened 
capsule,  and  becomes  widely  difl'used  through  the 
limb,  which  is  largely  oedematous ;  the  skin  is  ruddy 
or  dusky,  and  pits  deeply  on  pressure,  and  it  be- 
comes evident  that  not  only  the  joint  itself,  but 
also  the  adjacent  soft  structures  of  the  limb,  are  dis- 
organised. 

I>iag'nosis. — Abscess  outside  a  joint  may  resemble 
acute  arthritis.  In  external  abscess,  however,  there 
is  no  uniform  distension  of'  the  joint,  but  the  swelling 
is  irregularly  placed,  and  both  it  and  the  fluctuation  to 
which  it  gives  rise  are  confined  to  one  aspect  of  the 
articulation,  and  are  noticed  also  to  be  superficial  to 
the  various  bony  prominences  and  strong  ligaments, 
e.g.  the  patella  or  the  ligamentum  patellae ;  or  the 
olecranon  and  triceps  tendon.  The  joint  is  not  fixed, 
and  admits  of  ni ovemcnt  without  severe  pain;  fluctua- 
tion  is  distinct ;    tliere  is  no    abnormal  mobility   of 


Arthritis.  237 

the  ends  of  the  bones  on  each  other,  and  no  grating. 
Constitutional  disturbance  is  not  severe. 

Acide  traumatic  arthritis  sometimes  occurs  from  a 
severe  crush  or  wrench  j  it  usually,  however,  follows 
a  wound  in  which  infective  changes  have  taken  place. 
This  is  a  very  dangerous  form,  prone  to  pass  on  to 
suppuration,  and  rapid  disorganisation  and  destruction 
of  the  joint,  attended  with  high  temperature,  rigors, 
and  severe  constitutional  disturbance. 

Acute  infective  arthritis,  met  with  in  pyaemia,  puer- 
peral and  scarlet  fever,  and  other  allied  conditions,  is 
almost  equally  formidable  j  the  symptoms  are  usually 
acute ;  suppuration  ensues,  and  the  joint  is  quickly 
destroyed.  Another  variety  of  acute  arthritis  is  that 
which  is  secondary  to  disease  of  the  articular  ends 
of  the  bones,  as  met  with  chiefly  in  young  subjects 
during  the  growth  of  the  epiphyses.  Here,  as  sup- 
puration about  the  epiphysis  advances,  the  articular 
cartilage  is  perforated,  and  pus,  or  the  detritus  of  the 
ulcerative  process,  escaping  into  the  interior  of  the 
joint,  leads  to  a  violent  arthritis,  which,  in  the  course 
of  a  few  days,  entirely  destroys  the  articulation. 
Yery  rarely  acute  arthritis  occurs  from  the  extension 
of  erysipelas  or  cellulitis  to  the  interior  of  a  joint, 
or  from  the  bursting  into  it  of  an  abscess  in  the 
neighbouring  soft  parts,  e.g.  when  abscess  in  the 
popliteal  space  bursts  into  the  knee  joint. 

Treatiiieiit. — In  acute  arthritis,  the  first  point 
is  to  secure  rest  in  a  favourable  position.  Should 
suf)p\n-ation  ensue  the  matter  must  be  evacuated 
antiseptically.  Should  disorganisation  of  the  joint 
occur,  the  question  of  amputation  presents  itself. 
Where,  however,  arthritis  has  arisen,  in  the  course 
of  pyaemia  or  puerperal  fever,  or  of  any  of  the 
exanthemata  such  as  scarlatina  or  typhoid,  the 
general  condition  forbids  the  operation,  and  the 
treatment   must   be    expectant,   in    the  hope    that    a 


238  Manual  of  Surgery. 

stiff  joint  may  be  oLtaiiicd ;  or  that,  later,  as  the 
original  disease  subsides,  amputation  may  be  ventured 
upon.  In  the  arthritis  secondary  to  disease  in  the 
articular  ends  of  the  bones,  which  sometimes  is  very 
rapidly  destructi^•e,  and  which  is  most  frequent  in 
subjects  under  eighteen,  and  common  in  children 
of  five  or  six,  amputation  may  be  called  for.  It  can, 
however,  as  a  rule  be  avoided,  by  freely  opening, 
washing  out,  and  draining  the  joint ;  by  maintenance 
of  complete  rest ;  and  by  the  continued  use  of  antisep- 
tics. It  should  be  resorted  to  only  when  the  patient's 
general  condition  is  threatening  to  become  serious  to 
life,  as  shown  especially  by  rapid  wasting,  failure  of 
strength,  and  increasing  pallor,  the  results  of  pain, 
and  loss  of  appetite  and  sleep.  Should  acute  arthritis 
decline,  recovery  and  the  restoration  of  the  functions 
of  the  joint  may  be  promoted  by  the  means  alluded 
to  for  the  treatment  of  the  subacute  and  chronic 
forms  of  synovitis. 

The  acute  arthritis  of  infants^  described  by  Mr. 
T.  Smith,"^  is  referred  to  under  Epiphysitis. 

Epiphysitis. 

The  rapid  growth  which  in  early  life  takes  place 
between  the  epiphysis  and  the  shaft  of  the  long  bones, 
involves  an  instability,  as  the  result  of  which  healthy 
nutrition  is  apt  to  be  supplanted  under  the  influence 
of  feeble  health,  struma,  or  local  injury,  or  the  pre- 
sence of  some  septic  or  other  irritative  material  in  the 
blood,  by  inflammatory  action.  This  process,  termed 
epiphysitis,  is  not  usually  met  with  after  the  age  of 
eighteen  or  twenty,  when  nearly  all  the  epiphyses  have 
coalesced  with  the  shafts.  It  is  most  common  under 
the  age  of  ten.  It  may  be  acute,  subacute,  or  chronic; 
but  in  all  cases  alike,  one  of  the  main  dangers  is  that 
the  disease  may  extend  into,  and  lead  to  infla.mmation 
*  St.  Bartbol.  Hospl.  Reports,  vol.  x. 


Epiphysitis,  239 

of,  the  noigliljonring  joint.  It  is  now  well  known 
that  a  very  large  number  of  examples  of  joint  disease 
in  children  are  secondary  to  disease  originating  in  one 
of  the  adjacent  epiphyses.      (>S'ee  page  119.) 

The  acute  arthritis  of  iiiTants,  described  by 
Mr.  T.  Smith,  is  a  case  in  point.  Here,  generally  in 
infants  under  a  year,  and  often  only  a  few  weeks  old, 
sometimes  from  local  injury,  sometimes  from  absorp- 
tion of  septic  material  from  the  umbilical  cord,  or 
other  source,  the  epiphysial  line  of  growth  becomes 
the  seat  of  acute  inflammation,  quickly  running  on  to 
suppuration,  with  the  result  that  ptis,  breaking  down 
the  soft  tissue  of  the  epiphysis  itself,  travels  towards, 
and  soon  bursts  into  the  joint,  sometimes  by  a  mere 
pin-hole  orifice,  but  often  by  a  large,  ragged  opening 
in  the  articular  cartilage.  U]oon  this,  acute  inflam- 
mation of  all  the  structures  of  the  joint  ensues.  The 
articular  cavity  rapidly  becomes  distended  with  pus, 
the  synovial  membrane,  ligaments,  and  cartilages  are 
destroyed  by  ulceration,  and  even  the  articular  ends 
of  the  bones  themselves  are  lost,  so  that  disorganisa- 
tion of  the  joint  is  complete  ;  the  capsule  bursts,  and 
a  large,  plainly  fluctuating  periarticular  abscess  hold- 
ing sometimes  as  much  as  fifteen  ounces,  is  formed, 
and  burrows  widely  in  the  limb.  This  affection  may 
involve  any  of  the  large  joints,  but  the  knee,  hip,  and 
shoulder  most  often  suffer.  Sometimes  several  joints 
are  attacked  in  quick  succession.  The  malady  is  often 
fatal  by  exhaustion.  On  the  other  hand,  when  the 
case  is  seen  early,  and  matter  is  evacuated  before  the 
joint  is  involved;  or  if,  when  pus  has  reached  the 
joint,  the  articulation  is  at  once  freely  opened  and 
drained,  many  patients  recover,  and  may  even  retain 
perfect  movement  of  the  limb.  In  other  instances, 
though  the  patient  recovers,  the  joint  is  left  useless 
and  flail-like,  the  ends  of  the  bones  consisting  of  mere 
stumps  connected  by  fibrous  tissue. 


240  Manual  of  Surgery. 

The  treatment  consists  in  the  immediate  anti- 
septic evacuation  of  pus  (if  possible  before  it  reaches 
the  joint),  free  drainage  by  strips  of  guttapercha 
tissue,  the  use  of  a  splint  to  prevent  deformity,  and  of 
liquor  cinchonse  and  brandy  to  support  the  strength. 

In  subacute  or  chronic  epiphysitis  in  older  chil- 
dren, the  disease,  which  is  often  dependent  on  struma, 
usually  begins  at  the  junction  of  the  epiphysis  with 
the  shaft,  and  spreading  through  the  substances  of 
the  epiphysis  towards  the  joint,  produces  either 
chronic  synovitis ;  or,  if  matter  bursts  suddenly  into 
the  articulation,  a  violent  and  destructive  general 
arthritis. 

Syiuptoiiis. —  In  acute  epiphysitis  the  joint  is 
kept  in  a  fixed  position,  and  is  stiff,  painful,  and  ten- 
der. There  may  be  obvious  swelling  of  the  articular 
end  of  one  of  the  adjacent  bones,  with  tenderness  on 
pressure  and  redness  of  the  skin.  Within  a  few  hours 
after  it  is  reached  the  joint  becomes  distended  and 
the  swelling  rapidly  increases,  so  that  an  abscess 
bursting  through  the  capsule  forms  a  collection  of 
from  two  or  three  to  as  much  as  twelve  ounces  among 
the  muscles  of  the  limb.  In  epiphysitis  of  less  vio- 
lent character  the  symptoms  are  of  a  similar  nature, 
but  of  proportionately  diminished  severity. 

In  all  cases  of  epiphysitis  the  surgeon's  chief 
anxiety  must  be  to  avert  the  impending  affection  of 
the  joint.  In  the  early  stage  the  limb  must  be  kept 
at  rest  on  a  splint ;  in  acute  cases  one  or  two  leeches 
are  often  very  useful.  Should  matter  form  it  must  be 
at  once  let  out.  When  swelling,  local  tenderness, 
pain,  and  high  temperature  indicate  that  matter  is 
probably  enclosed  in  the  epiphysis,  an  incision  should 
be  made  over  the  tender  spot,  and  the  epiphysis 
should  be  cautiously  perforated.  If  matter  is  found, 
an  adequate  j)ortion  of  the  superficial  wall  of  the 
cavity  containing  it  should  be  removed  so  that  pus 


EriPHi  'SJ  T/s.  241 

may  readily  escape  towards  the  surface.  Though 
not  invariably,  yet  frequently,  the  cases  described  by 
Brodie,  as  chronic  abscess  in  the  articular  extremity 
of  the  tibia  (a  similar  condition  is  met  with  in  other 
bones),  are  examples  of  chronic  epi^^hysitis,  followed 
by  suppuration. 

When  the  epiphysis  at  the  growing  end  of  one  of 
the  bones  (the  upper  end  of  the  humerus  and  tibia, 
the  lower  end  of  the  femur,  radius,  and  ulna)  has  been 
long  involved  in  slight  chronic  inflammation,  the 
increased  blood  supply  may  lead  to  increased  growth, 
and  the  limb  may  become  an  inch  or  even  two  inches 
longer  than  its  fellow.  On  the  other  hand,  should 
epiphysitis  have  been  acute  and  destructive,  the  sub- 
sequent growth  of  the  bone  may  be  to  a  gi'eat  extent 
arrested.  Last  year  I  saw  a  girl,  aged  nineteen,  at 
St.  Bartholomew's  Hospital,  whose  humerus,  the 
upper  end  of  which  had  been  the  seat  of  destructive 
epiphysitis  in  infancy,  was  four  inches  shorter  than 
its  fellow. 

A  formidable  and  not  rare  effect  of  acute  e})iphy- 
sitis  and  ulceration  in  the  line  of  junction  with  the 
shaft,  is  the  complete  detachment  of  the  epiphysis. 
The  upper  epiphysis  of  the  femur,  when  thus  separated, 
being  left  without  adequate  blood  supply,  perishes,  and 
forms  a  sequestmm.  In  the  case  of  other  epiphyses^  how- 
ever, though  necrosis  is  still  the  rule,  repaii-  may  occur, 
and  the  epiphysis  may  regain  its  attachment.  Duiing 
epiphysitis,  especially  at  the  upper  end  of  the  tibia, 
though  no  complete  separation  occurs,  the  connection  of 
the  epiphysis  and  the  shaft  may  be  so  weakened,  that, 
either  at  the  time,  or  during  subsequent  use  of  the 
limb,  the  junction  may  yield,  and  a  deformity  which 
is  very  difficult  to  remove,  and  which  greatly  impaii-s 
the  use  of  the  limb,  is  produced.  Should  displacement 
be  observed,  it  must  be  at  once  arrested  by  appropriate 
mechanical  support. 
(^—21 


2  42  Manual  of  Surgery. 

ScEOFULOUS  Diseases  of  the  Joints. 

We  are  still  without  a  concise  and  adequate  defini- 
tion of  scrofula,  or  its  synonym,  struma.  We  can  only 
say  that  it  is  a  defective  condition  of  the  general  health, 
with  a  tendency  to  various  forms  of  chronic  inflamma- 
tion, as  of  the  lymph  glands,  cancellous  bone,  mucous 
and  synovial  membranes,  and  the  skin,  tending  to  pass 
on  to  suppuration  and  caseation  of  the  efiiised  pro- 
ducts. In  a  considerable  number  of  instances  well- 
marked  tubercle  is  present,  while  in  other  cases  of 
more  limited  duration  or  of  lower  intensity,  no  histo- 
logical elements  beyond  those  of  mere  chronic  intiam- 
mation  are  produced.  The  scrofulous  process  arises 
either  when  healthy  nutrition  fails  and  deviates,  apart 
from  any  obvious  external  cause,  into  a  low  form  of 
chronic  inflammatory  action  of  the  type  just  men- 
tioned ;  or  when  the  same  result  follows  disturbance 
of  nutrition  by  some  local  agency,  such  as  injury, 
etc.    {See  page  131,  and  page  216,  vol.  i.) 

Tlie  chief  clinical  characters  of  scrofulous  inflam- 
mations are  their  origin,  either  spontaneously,  or  as 
the  result  of  some  trivial  local  injury  which  in  a  healthy 
subject  would  have  been  quickly  repaired  ;  their  ten- 
dency to  suppuration  and  caseation  ;  their  proneness 
to  advance,  extend,  and  relapse ;  their  occurrence 
chiefly  in  phthisical  families ;  their  multiple  develop- 
ment in  the  same  family,  or  in  the  same  patient ;  and 
their  prevalence  between  the  ages  of  three  and  seven, 
a  period  of  life  during  which  general  tuberculosis 
and  tubercular  meningitis  are  more  frequent  than  at 
any  other  time,  and  when  local  injury  is  certainly 
not  more  common  than  it  is  a  few  years  later. 

When  we  meet  with  children  who  come  of  a 
phthisical  stock,  and  who  sufler  without  any  obvious 
cause  from  a  variety  of  tedious  local  inflam- 
mations ;  when,   in  the  same  family,  several  cliildren 


Sm  UMO  us  Joint  Disea  se.  243 

are  affected  ;  and  when  it  is  observed  that  as  one 
inflammatory  lesion  is  slowly  repaired,  or  while  it 
is  still  in  progress,  others  are  developed  under  con- 
ditions that  exclude  the  ordinary  exciting  causes  of 
inflammation  in  healthy  subjects,  we  appear  to 
be  dealing  with  a  morbid  condition  quite  as  defi- 
nite as  manv  to  which  distinct  names  are  assigned, 
and  one  for  which,  at  least  for  the  sake  of  conve- 
nience, some  general  heading  should  be  used.  Yet 
former  conceptions  of  scrofula,  as  to  its  inve- 
teracy, its  inevitably  destructive  action,  and  its 
association  with  any  profound  dyscrasia,  undoubtedly 
require  revision.  These  chronic  inflammatory  pro- 
cesses, which  we  gi'oup  under  this  name  of  scrofula, 
are  very  much  what  they  are  allowed  to  become. 
Probably  no  affections  are  more  dependent  on  exter- 
nal conditions,  on  the  difference  between  careful 
treatment. and  neglect.  Many  a  child,  who,  between 
the  ages  of  three  and  seven,  is  the  subject  of  various 
forms  of  scrofulous  inflammation,  such  a-s  caries  of 
the  spine  and  of  tlie  tarsus ;  ophthalmia  or  otor- 
rhoea  or  oza^na,  if  w^ell  managed,  subsequently 
becomes  to  all  appearance  perfectly  healthy,  and 
remains  free  from  any  return  of  these  affections. 
Present  experience,  indeed,  clearly  demonstrates  that 
the  traditional  view  of  scrofula  has  been  derived  from 
cases  in  which  the  disease,  allowed  to  run  its  course, 
has  attained  a  stage  of  development  and  assumed 
characters  which  appropriate  treatment  would  easily 
have  prevented.  In  short,  when  it  is  opposed  in  its 
outset  and  subsequently  by  suitable  treatment,  scrofula 
in  the  great  majority  of  cases  is  merely  a  chronic  in- 
flammatory process,  formidable  in  no  other  sense  than 
'that  it  is  tedious  and  prone  to  relapse.  These  observa- 
tions w-ill  now  be  applied  to  scrofulous  diseases  of 
the  joints. 

These  affections  are  most  often  developed  between 


244  Manual  of  Surgery. 

the  ages  of  three  and  seven  or  eight,  and  although 
they  not  rarely  commence  after  this  period,  they 
grow  more  and  more  infrequent  as  age  advances.  The 
disease  takes  its  origin  either  in  the  synovial  mem- 
brane or  the  ends  of  the  bones,  but  with  what  relative 
frequency  it  is  not  easy  to  say.  It  must  here 
suffice  to  state  that  synovitis  is  common  in  all  the 
joints  except  the  hip,  though  here  also  it  is  cer- 
tainly met  with.  In  this  joint  disease  most  fre- 
quently begins  in  the  bones,  either  the  head  of  the 
femur  or  the  acetabulum.  When  disease  arises  in  the 
articular  ends  it  commences  either  just  beneath  the 
cartilage  (subchondral  caries),  in  the  epiphysial  line  of 
growth,  or  in  some  spot  in  the  cancellous  tissue,  often 
in  the  neighbourhood  of  the  ossific  nucleus.  It  sub- 
sequently involves  the  joint  by  extension  of  the  in- 
flammatory process,  either  gradually  or  by  the  sudden 
entrance  of  pus  into  the  articular  cavity. 

Symjytoms. — Scrofulous  synovitis,  of  which  a  good 
illustration  is  found  in  the  knee,  is  usually  chronic, 
constituting  white  swelling  or  tumor  albus.  It  may, 
however,  be  more  or  less  acute,  either  when  it  follows 
injury,  or  is  secondary  to  disease  originating  in  the 
bones.  In  the  usual  chronic  form  the  joint  is  a 
little  flexed,  and  cannot  be  completely  straightened ; 
movement,  though  it  may  be  free  in  the  middle 
range,  is  restricted  before  the  extreme  natural  limits 
are  reached  ;  there  is,  though  it  may  be  slight,  pufiy 
swelling  of  the  synovial  membrane,  most  apparent 
where  the  joint  capsule  is  thin.  Some  abnormal  heat 
may  be  detected  with  the  hand  or  the  surface  ther- 
mometer, but  it  is  often  inappreciable.  Pain,  it  is 
most  important  to  notice,  is  often  entirely  absent ; 
lameness,  though  almost  invariably  present,  may  be 
so  slight  as  to  escape  all  but  a  very  observant  exami- 
nation. Muscular  wasting  soon  occurs,  and  is  often 
one   of   the   most   trustworthy   symptoms.     For    the 


Strumous  Joint  Disease.  245 

symptoms  met  with  in  particular  joints,  see  under 
"  shoulder,"  "  elbow,"  etc. 

All  the  above  symptoms  must  be  critically  inves- 
tigated, for  undoubtedly  incipient  strumous  disease 
is  unfortunately  often  overlooked,  and  the  aflfection, 
thus  left  to  itself,  steadily  advances,  and  frequently, 
by  involving  other  structures,  passes  on  to  a  general 
arthritis.  Under  these  circumstances  the  membrane 
becomes  thickened  and  gelatinous  (pulpy  degenera- 
tion), the  ligaments  and  cartilages  are  eroded,  or  in 
great  part  destroyed,  and  the  joint  on  manipulation  is 
often  abnormally  "loose";  while  in  the  knee,  hip,  and 
wrist  serious  displacement  occurs.  Effusion  is  seldom 
present  in  any  large  amount,  but  slow  suppuration 
may  lead  to  the  formation  of  flaky  or  cheesy  pus.  In 
other  instances  the  inflammation  is  plastic,  and 
the  efiused  lymph  undergoes  organisation,  so  that 
although  the  disease  has  never  assumed  an  active 
form,  and  no  suppuration  has  taken  place,  firm 
fibrous  or  even  bony  ankylosis  may  occur.  These 
cases  of  "  quiet  "  strumous  disease,  ending  in  absolute 
stiffness^  are  more  common  than  many  suppose.  When 
mischief  begins  in  the  ends  of  the  bones  (^^ee  Epiphysitis) 
the  joint  is  at  first  free ;  but  there  is  enlargement,  to- 
gether with  pain,  tenderness,  and  puffy  swelling  at  the 
seat  of  disease,  and  local  heat ;  while,  as  soon  as  the 
joint  is  reached,  the  symptoms  of  synovitis,  above 
described,  become  apparent.  Sometimes  synovitis 
remains  slight  and  subacute,  often  with  intervals  of 
apparent  recovery ;  in  others,  when  the  joint  is 
suddenly  inoculated  with  pus,  acute  arthritis  is 
immediately  developed. 

Treatment. — It  is  a  law  to  which  no  exception 
can  be  safely  made,  that  a  strumous  joint  must  be 
kept  at  absolute  rest.  The  view  that,  because  the 
disease  is  ''  constitutional,"  local  treatment  is  not  so 
important  as  that  the  patient  should  have  exercise  in 


246 


Manual  of  Surgery. 


the  open  air,  is  completely  erroneous.  Fresh  air  is,  of 
course,  of  the  highest  value  as  an  adjunct  to  local 
treatment.  Yet  local  treatment  must  invariably  stand 
first.  If  these  joints  are,  from  the  onset  of  the  disease, 
kept  at  rest,  their  recovery,  often  with  completely  free 
movement,  is,  in  the  great  majority  of  cases,  merely 
a  question  of  time.  Even  those  that  are  more 
or  less  stiff  are  strong,  useful,  and  free  from  defor- 
mity. For  the  details  of  the  treatment  of  hip  disease 
see  page  287.     The  knee  is  best  enclosed  in  leather 


Fig.  51.— Leather  Splint  for  Knee. 


splints  {see  Fig.  51)  till  all  active  disease  has  sub- 
sided. Then  Thomas's  splint  may  be  used.  The  re- 
maining joints  should  be  kept  in  leather  splints  (Figs. 
52,  53,  54),  these  being  removed  every  two  or  three 
days,  while  the  skin  is  gently  sponged  and  dried,  and 
then  immediately  re-applied.  In  the  meantime,  the 
patient  must  not  put  his  foot  to  the  ground,  or  make 
any  use  whatever  of  the  joint.  Everything  depends 
on  the  absolute  manner  in  which  these  rules  are  carried 
out.  If  matter  forms  it  should  be  evacuated  anti- 
septically. 

The  pei-iod  required  for  recovery  must  vary  with 
the  case  ;  from  three  months,  to  nine  or  even  twelve 
months,  being  the  necessary  time ;  while  if  the 
disease  is  already  of  long  standing  the  time  must 
be  extended  to  eighteen  months  or  even  two  years. 
Excellent    recoveries  may  be  thus  secured,   in  cases 


Strumous  Joint  Disease. 


247 


that  v/oiild  otherwise  come  to  excision  or  amputation. 
It  is  quite  certain  that  if  the  patient  is  well  fed,  and  is 
in  a  well-aired  room,  or  in  the  open  air  when  the  weather 
is  suitable,  enforced  rest  will  not  materially    impair 


Fig.  52.— Leather  Splint  for  Elbow. 


the  general  health.  The  period  of  rest  must  in  each 
case  be  determined  by  the  previous  duration  of  the 
disease,  and  the  readiness,  or  the  reverse,  with  which 


Fig.  53.— Leather  Splint  for  Wrist. 


the  symptoms  subside.  As  a  rule,  however,  rest 
should  be  maintained  for  at  least  three  months  after 
all  signs  of  disease  have  disappeared,  and  active  exercise 
should  be  very  gradually  renewed.  The  danger  always 
is  that  it  may  be  resumed  too  soon.  It  is  a  common 
belief  that  if  joints  are  kept  long  in  a  hxed  position 
they  will  become  stitf.     This  is  a  fallacy.     Stitlhess 


248 


Manual  of  Surgery. 


results  when  inflammatory  action  has  led  to  ankylosis. 
Hence  the  surest  way  to  avoid  this  result  is  to  subdue 
the  inflammation  by  rest.  Many  a  joint  retains 
unimj)aired  motion  after  it  has  been  at  rest  for  six 
months,  or  even  for  upwards  of  a  year.  In  those 
cases,  and  tliey  undoubtedly  occur,  in  which  stifihess 
follows  long  rest,  the  result  is 
due  not  to  rest,  but  to  the 
plastic  character  of  the  inflam- 
matory [)rocess.  Another  fallacy 
is  that  joints  often  become 
permanently  fixed  by  muscular 
rigidity  ensuing  during  enforced 
rest.  Such  a  result  is,  to  say 
the  least,  very  rare. 

With  local  rest  must  be 
combined  a  dry  climate,  fresh 
air  near  the  sea,  where  this  is 
practicable,  nutritious  diet,  warm 
clothing,  and  tonics,  of  which 
cod-liver  oil  is  the  best  during 
cool  weather,  and  the  more  easily 
digested  preparations  of  iron  in 
the  summer  months. 

Before  leaving  this  sul)ject 
reference  may  be  made  to  "senile 
scrofula,"  a  term  given  by  Sir 
James  Paget'^  to  cases  in  every 
respect  resembling  scrofulous  affections  as  they  are  met 
with  in  children  and  adolescents,  except  that  they  occur 
in  persons  from  fifty  years  of  age  and  upwards,  some- 
times in  patients  past  seventy.  Diseases  of  this 
nature  attacking  the  joints,  usually  the  wrist  and 
elbow,  but  occasionally  the  hip,  knee,  and  other 
articulations,  either  spontaneously  or  after  some  slight 
local  injury,  run  sometimes  a  chronic,  but,  in  other 
*  Ciin.  Lectures  and  Essays. 


Fig.  54.  —Leather  Spliut 
for  Ankle. 


Pulpy  Degeneration.  249 

instances,  a  rapid  and  destructive  course,  quickly- 
going  on  to  suppuration  and  disorganisation  of  the 
joint.  Even  in  their  milder  forms  they  prove  little 
amenable  to  treatment,  which  should  be  that  already 
laid  down  for  scrofula  :  while  when  they  are  acute 
they  quickly  advance  to  a  stage  in  which  amputation 
may  become  necessary. 

Pulpy  deg^eiieration.  —  Tins  term  has  como 
down  to  us  from  Sir  B,  Brodie,  who  applied  it  to  in- 
stances in  which  "  the  syno^^.al  membrane  was  con- 
verted into  a  brown  pulpy  soft  mass,  from  a  quarter  of 
an  inch  to  an  inch  in  thickness,  intersected  by  white 
membranous  lines,  and  studded  with  red  spots,  formed 
by  small  injected  blood-vessels,"  while  "  vascular 
fringes  projected  into  the  cavity  of  the  joint,  a  good 
deal  resembling,  both  in  appearance  and  structure, 
the  appendices  epiploicae  of  the  large  intestine.  The 
semilunar  cartilages  were  entire,  but  were  in  a  great 
measure  concealed  by  the  pnlpy  substance  projecting 
over  them.  The  cartilages  were  in  a  state  of  in- 
cipient ulceration. "  Observing  that  at  the  commence- 
ment of  these  cases  there  was  neither  pain,  tenderness, 
nor  other  sign  of  inj3ammation  present,  that  the  en- 
largement of  the  joint  began  almost  imperceptibly, 
and  increased  steadily,  and  that  there  was  no  pain 
even  on  movement,  Brodie  held  that  the  disease  was 
"no  more  inflammatory  in  its  origin  than  morbid 
growths  generally  are  in  other  organs."  Later  re- 
search, however,  has  shown  that  these  changes  are 
not  dependent  on  any  form  of  new  growth,  but  that 
they  are  due  to  an  insidious  and  frequently  intractable 
form  of  chronic  inflammation  of  the  synovial  membrane, 
often  tubercular  in  character.  Hence,  by  common 
consent,  the  term  pulpy  degeneration  is  dying  out,  and 
is  now  seldom  mentioned,  except  (as  here)  to  avoid 
confusion  as  to  the  sense  in  which  it  was  originally 
used. 


250  Manual  of  Surgery. 

Loose  Bodies. 

These  are  most  common  in  tlie  knee,  but  tliey 
are  also  occasionally  found  in  the  elbow,  hip,  and 
shoulder.  In  the  other  joints,  though  not  unknown, 
they  are  extremely  rare.  They  present  the  following 
varieties  : 

1.  Though  Hunter's  view,  that  coagulated  blood 
in  a  joint  might  undergo  conversion  into  a  mass  of 
cartilage   or  bone,  was  erroneous,  those  loose  bodies 

which  present  a  merely  fibri- 
nous structure  may  possibly 
(though  clear  proof  is  wanting) 
be  derived  from  altered  blood 
clot. 

2.  Blood  extravasated  into 
a  synovial  fringe  may  become 
organised  and  form  a  peduncu- 
lated body,  and,  when  the  stalk 
^,    ^        ^  -,    ^         srives  way,  fall  loose  into  the 

55. — Loose  Body  from     ^  •    i  • ,  a 

Joint.  synovial     cavity.        fepecimens 

exist  to  show  this. 

3.  When  a  synovial  fringe  or  a  patch  of  sub- 
synovial  tissue  has  become,  from  injury  or  some  other 
cause,  enlarged  and  thickened,  and  when  it  is  caught 
and  dragged  upon  by  the  movements  of  the  joint,  its 
base  is  gradually  drawn  out  into  an  elongated  pedicle, 
and  it  becomes  a  floating  body.  Such  a  body  may 
long  remain  attached  ;  l)ut  its  stalk  may  at  length 
give  way  so  that  it  falls  free  into  the  cavity  of  the 
joint  (Fig.  55).  Bodies  of  this  origin  consist  of  con- 
nective tissue  and  fat,  often  mixed  with  inflammatory 
products,  covered  with  endotheliujn. 

4.  Synovial  fringes,  hypertrophied  in  the  course  of 
chronic  rheumatic  disease,  or  of  osteo- arthritis,  often 
become  converted  into  cartilaginous  bodies  by  over- 
growth of  the  cartilage  cells,  which,  as  pointed  out  by 


Loose  'Cartilages. 


251 


Rainey  and  Kolliker,  are  normally  present  in  them. 
These  bodies  remain  for  a  time  attached  Ly  a  pedicle 
(Fig.  56),  but  this  at  last  gives  way  and  they  become 
free.  Such  bodies  consist  of  hyaline  cartilage,  or  of 
fibro-cartilage  which,  however,  may  undergo  calcareous 
degeneration,  or  be  converted 
into  true  bone. 

5.  After  a  severe  contusion 
or  other  local  injury,  a  portion 
of  articular  cartilage  may,  as 
desciibed  by  Sir  James  Paget, 
undergo  "  quiet  necrosis,"  that 
is,  may  perish  independently  of 
any  overt  sign  of  inflammation, 
and  be  shed  into  the  joint  (Fig. 
57).  In  other  cases  the  mass  so 
necrosed  and  cast  off  includes 
not  only  the  articular  cartilage, 
but  also  a  portion  of  the  sub- 
jacent bone  (Fig.  58). 

6.  Or  a  piece  of  cartilage, 
or  cartilasfe  and  some  of  the  sub- 
jacent  bone,  may  be  chipped  off, 
and  fall  into  the  joint. 

7.  The  nodular  masses  that 
form  about  the  joints  in  osteo- 
arthritis may  project  into  the  articular  cavity  attached 
by  a  thread  of  synovial   tissue    acting   as    a  pedicle. 
In  many  cases  the  pedicle  at  length  snaps  and  they 
are  free  (Fig.   59). 

8.  Mr.  Shaw  has  recorded  a  case  in  which  a  loose 
body  was  found,  on  removal,  to  contain  the  point  of 
a  broken  needle.  Probably  the  needle,  accidentally 
embedded  in  the  subsynovial  tissue,  had,  by  causing 
irritation,  led  to  the  formation  of  the  body  which  had 
subsequently  become  detached. 

Joints   in    which   loose    bodies  are  contained   are 


Fig.  56. 


-Loose  Bodies  in 
Joint. 


252 


Manual  of  Surgery, 


often  otherwise  healthy,  or  subject  from  time  to  time 

merely  to  slight  inflammatory  attacks  when  the  body 
is  caught  between  the  articular  sur- 
faces  so  as  to  inflict  mechanical 
injury.  In  classes  4  and  7,  and 
often  in  class  3,  the  joint  is  the  seat 
of  chronic  rheumatism,  or  osteo- 
arthritis. In  hydrarthrosis  the 
synoyial  membrane  often  presents 
nodular  masses  of  cartilage,  or  thick 
fringes  that  produce  analoijous 
symptoms. 

Loose  bodies  are  fi'equently 
single,  but  their  number  is  subject 
to  wide  yariety.  In  osteo-arthritis 
there  are  often  as  many  as  from 
six  to  twenty  or  more.  Lately,  at 
St.  Bartholomew's  Hospital,  Mr.  T. 
Smith  remoyed  415  bodies  from  a 
knee  joint ;  of  these  only  five  or  six 
were  attached.  The  jmthology  of 
this  remarkable  case  was  obscure. 
Symptoms. — These  yary  with 

the  nature  of  the  body  itself,  and  the  condition  of  the 

joint  in  whicli  it  is  present.     In  a 

typical  case  (e.g.  of  quiet  necrosis, 

or  in  \yhich  a  mass  of  cartilage  has 

formed  in  a  hypertrophied  synoyial 

fnnge,  and  has  become   detached, 

the  joint  being  otherwise  healthy), 

the  patient  while  walking  is  seized 

with  such  agonising  pain,  coming 

on  as  suddenly  as  if  he   had  re- 
ceived   a    blow,    that,    losing    all 

power  in  the  limb,  he  falls,  oyercome  witli  a  sense 

of  momentary  faintness.     Sometimes  the  joint  remains 

freely  moyable,   and  the  patient  can  walk,  when  in 


Fig.  57.— Loose  Body 
from  Joint. 

A,  Anterior,  !ind  b,  pos- 
tf  rior  gurfacc. 


Fig.  58.— Loose  Body 
from  Joint. 


Loose  Cartilages.  253 

the  course  of  a  few  minutes  the  pain  goes  off.  In 
other  cases  the  limb  becomes  fixed  at  an  angle  of  about 
130*^,  and  any  attempt  at  movement  causes  unbearable 
suffering.  This  stiffness  may  remain  for  a  time,  and 
then,  on  some  movement  of  the  limb,  suddenly  dis- 
appear. It  may,  however,  continue  till  the  joint  is 
surgically  manipulated.    {See  page  258.)    The  accident 


Fig.  59.— Loose  Bodies  from  Joint. 

is  followed  by  sharp  synovitis  indicated  by  pain,  heat, 
swelling,  and  stiffness  lasting  two  or  three  days. 

Often  the  patient  detects  the  body,  and  ascertains 
either  that  it  remains  in  one  situation  (when  attached), 
or  shifts  to  different  parts  of  the  joint.  Probably 
loose  bodies  are  most  commonly  felt  in  the  pouch 
over  the  external  condyle  of  the  femur.  The  agonising 
pain  alluded  to  is  produced  when  these  bodies  are 
caught  between  the  joint  surfaces,  so  that  the  liga- 
ments are  severely  stretched  and  the  articular  surfaces 
contused  by  the  powerful  leverage  with  which  the 
bones  act  upon  each  other. 

The  articulation  remains  fixed  when  the  body  is 
caught  and  held  like  a  stone  in  the  hinge  of  a  gate, 
but  usually  the  cartilage  slips  away  as  pressure 
increases,  and  the  joint  is  freely  movable  again. 
The  symptoms  may  return  frequently  when  the  body 


2  54  Manual  of  Surg  fry. 

is  of  moderate  size  and  movable.  But  when  it  is 
large,  and  can  be  cauglit  only  in  certain  positions,  the 
attacks  occur  at  wider  intervals ;  once  a  month,  or 
even  in  three  or  four  months.  In  osteo-arthritis,  or 
other  conditions  in  which  the  joint  is  extensively 
diseased,  the  symptoms  are  much  less  characteristic  ; 
but  there  is  still  the  occurrence  of  sudden  pain 
coupled  with  arrest  of  movement,  and  the  fact  that 
either  the  patient  or  the  surgeon  detects  the  body. 

Treatment. — Formerly  the  complications  ensuing 
upon  wounds  of  the  large  joints  were  so  formidable 
that  the  removal  of  loose  bodies  by  cutting  down  upon 
them  (the  "  direct  method  ")  involved,  as  numerous 
published  tables  have  shown,  a  mortality  of  at  least 
twenty  per  cent.  This  was  considerably  reduced  by 
the  introduction  of  the  valvular  or  "  indirect  method." 
In  this,  an  instrument  like  a  large-sized  tendon  knife, 
but  with  its  blade  mounted  on  a  long  shank,  is  passed 
through  the  skin  at  a  distance  of  an  inch  and  a  lialf  from 
the  cartilage,  and  is  carried  horizontally  onwards  till 
the  body  is  reached.  The  synovial  membrane  is  then 
freely  divided,  and  the  knife,  when  it  has  been 
slightly  withdrawn,  is  moved  from  side  to  side  in  the 
subcutaneous  fat,  so  that  a  space,  or  a  pocket,  is 
formed.  Into  this  the  cartilage  is  slipped.  Here  it 
may  be  allowed  to  remain  permanently,  or,  when  the 
wound  in  the  synovial  membrane  has  healed,  it  may 
be  cut  down  upon  and  removed.  A  serious  drawback 
to  this  method  is  that  it  is  apt  to  fail,  even  in  the 
hands  of  experienced  operators,  either  because  the 
synovial  membrane  has  been  insufficiently  divided,  or 
a  large  enough  space  has  not  been  formed  in  the  peri- 
articular fat  for  the  reception  of  the  cartilage,  or 
because  the  cartilage  is  not  free,  but  still  attached 
within  the  joint. 

Hence,  at  the  present  day,  when  it  is  the  ex- 
perience of  every  surgeon  that  if  due  precautions  are 


Loose  Cartilages.  255 

taken  to  avoid  the  entrance  of  septic  materials  tlie 
large  cavities,  like  the  peritoneum,  may  be  safely 
opened,  the  direct  method  is  almost  exclusively  in  use. 
It  is  thus  performed :  The  cartilage  is  securely  held 
(at  some  spot  where  the  joint  capsule  is  thin)  by 
transfixing  it  with  one  or  two  strong  steel  needles, 
(of  which  a  trustworthy  assistant  should  have  charge), 
exposed  by  a  careful  dissection,  and  extracted.  Any 
bleeding  should  be  arrested  before  the  joint  is  opened. 
If  the  body  is  attached  its  pedicle  must  be  divided, 
having,  should  it  appear  vascular,  been  first  tied  with 
fine  catgut.  The  wound  is  then  brought  together 
with  fine  catgut  sutures,  which  should  include  the 
synovial  membrane,  and  dressed  with  carbolic 
gauze  ;  and  the  limb  is  placed  on  a  back  splint  so 
that  absolute  rest  is  maintained.  Healing  generally 
takes  place  by  the  first  intention,  and  there  is 
no  rise  of  temperature.  This  proceeding,  properly 
carried  out,  is  so  free  from  risk  that  it  may  be 
recommended  without  hesitation  in  cases  in  which 
the  joint  is  free  from  advanced  disease,  and  the  patient 
is  sound  and  not  far  past  middle  age ;  and  it  may  be 
regarded  as  in  all  respects  preferable  to  the  indirect 
method.  In  instances  of  osteo-arthritis  or  rheumatic 
disease,  in  otherwise  sound  patients,  in  whom  multiple 
adventitious  bodies  materially  interfere  with  the 
functions  of  the  joint,  all  those  that  are  completely 
loose,  or  that  can  easily  be  removed,  should  be  extracted; 
while  others  should  be  left  till  they  become  trouble- 
some ;  in  elderly  or  unsound  patients  it  is  best  not  to 
operate,  especially  if,  as  is  not  rarely  the  case,  a  knee 
cap  or  a  pad  and  bandage  suffices,  as  the  joint  is  no 
longer  the  seat  of  vigorous  movement,  to  relieve  the 
symptoms. 

The  diagnosis  between  cases  of  loose  bodies  and 
cases  of  internal  derangement  of  the  knee  joint  may 
be  gathered  by  referring  to  page  257. 


256  Manual  of  Surgery. 

Displaced  Semilunar  Cartilage. 

Hey,  under  the  title  of  internal  derangement,  and 
Sir  Astley  Cooper  under  that  of  subluxation  of  the  knee 
joint,  were  among  the  first  to  point  out  the  main  clinical 
symptoms  of  cases  in  which  the  semilunar  cartilages  of 
the  knee  are  displaced.  The  general  impression  that 
the  internal  cartilage  is  most  often  involved  is  probably 
true,  but  cases  are  not  rare  in  which  the  external  is 
at  fault.  The  following  conditions  are  met  with  :  (a) 
In  a  healthy  joint,  during  a  violent  effort,  often  of  rota- 
tion, one  of  the  cartilages  at  some  part  of  its  circum- 
ference may  either  protrude  or  slip  inwards,  in  rela- 
tion to  the  condyle  of  the  femur.  In  such  cases  either 
a  prominent  rim  or  a  deep  sulcus  may  exist  over 
the  site  of  the  cartilage.  (6)  The  strain  on  the  carti- 
lage may  be  so  great  that  its  marginal  attachments 
are  partly  or  completely  torn  through,  and  the  disc 
may  be  displaced,  its  anterior  portion  slipping  back 
entirely  behind  the  corresponding  condyle ;  or  the 
whole  cartilage  slipping  inwards,  so  as  to  lie  in  the 
middle  line,  in  the  intercondyloid  notch  of  the  femur, 
(c)  The  cartilage  may  not  only  be  uprooted  at  its  cir- 
cumference, but  be  also  torn  across,  so  as  to  slip  about 
like  a  pedunculated  loose  body,  (d)  The  end  attach- 
ment of  one  of  the  cartilages  may  be  torn  away, 
bringing  with  it  a  fragment  of  the  tibia,  (e)  In  cases  of 
old  synovitis,  especially  in  rheumatic  subjects,  the 
attachments  of  the  cartilages  become  elongated,  so  that, 
acquiring  too  wide  a  range  of  movement,  they  fre- 
quently slip  out  of  place.  {/)  After  injury,  the 
external  cartilage,  and  perhaps  the  internal,  though 
I  have  seen  no  examples,  may  become  enlarged  and 
thickened,  so  that  on  certain  movements  of  extension 
and  rotation  it  protrudes  widely,  and  can  be  very  dis- 
tinctly felt.  I  have  met  with  two  cases  in  which 
this  condition  was  very  clearly  marked.     (^)  R.  W. 


Displaced  Cartilages.  257 

Smith  has  recorded  a  case  in  wliich  the  internal 
cartilage  was  accidentally  transfixed  by  a  hackle 
pin,  and  apparently  torn,  or  partially  separated, 
from  its  connections,  so  that  it  could  be  felt 
protruding  beneath  the  cicatrix  of  the  wound,  where 
it  interfered  considerably  with  tlie  movements  of  the 
joint.  Displacement  of  these  cartilages,  though  most 
common  dui-ing  the  vigorous  period  of  adult  life,  may 
occur,  as  the  result  of  injury,  in  children  of  six  or  eight, 
or  in  elderly  persons  whose  joints  are  the  seat  of 
chronic  rheumatic  eiiiision.     {See  page  200.) 

Syiiiptoins. — These  vary  with  the  nature  of  the 
case.  When  in  a  healthy  joint  the  cartilage  is  diiven, 
by  a  sudden  screw  movement  of  the  femur  and 
tibia  on  each  other,  out  of  place,  but  without  lacera- 
tion of  its  attachments,  the  pain  at  the  moment  is  as 
severe  as  that  attending  the  slip  of  a  "  loose  cartilage," 
and  the  joint  is  found  partially  flexed  and  "locked," 
and  peuhaps  with  some  deviation  of  the  axis  of  the 
tibia,  often  in  the  direction  of  abduction.  The  i)atient 
cannot  usually  move  the  joint,  yet  on  manipulation, 
though  it  is  locked  against  full  extension,  it  admits  of 
partial  flexion. 

Sometimes  the  disc  is  felt  protruding ;  or  it  may 
have  so  slipped  inwards  as  to  cause  a  deep  tucking  in 
of  the  skin ;  often,  however,  nothing  can  be  seen  or 
felt  on  external  examination,  and  the  accident  must 
be  inferred  from  the  "  locked  "  condition  of  the  knee. 
In  a  few  hours  all  the  signs  of  a  more  or  less  acute 
synovitis  generally  come  on. 

When  the  attachments  of  the  disc  are  widely  torn, 
the  cartilage,  from  the  moment  of  the  injury,  slips 
freely  about,  and  the  joint  goes  "  in  "  and  "  out "  with 
every  attempt  at  movement.  Subsequently  the  sHp 
becomes  less  frequent,  and  occurs  only  on  certain 
movements,  usually  of  flexion,  or  flexion  combined 
with  rotation. 
E— 21 


258  Manual  of  Surgery. 

Many  patients  know  exactly  how  to  put  the 
"joint  out,"  and  can  thus  materially  help  the  surgeon 
in  formincj  a  diamiosis.  In  cases  in  which  the  attach- 
nients  of  the  cai-tilage  have  become  relaxed  by  chronic 
synovitis,  or  otherwise,  the  joint  is  liable  to  become 
suddenly  locked  and  painful  on  any  casual  movement ; 
e.g.  as  the  patient  rises  from  his  chair,  turns  in  bed,  or 
crosses  one  knee  over  the  other.  Sometimes  tlie  lock 
is  only  momentary ;  in  other  cases  the  joint  remains 
fixed.  The  slip  is  at  first  followed  by  synovitis,  but 
after  a  time  the  joint  becomes  more  tolerant,  and  the 
subsequent  heat  and  swelling  are  little  marked.  In 
the  intervals  between  the  attacks  the  joint  is,  to  all 
appearance,  normal. 

Treatment. — In  many  cases,  though  the  "  slip  " 
causes  some  momentary  pain,  and  is  followed  by  two 
or  three  days  of  synovitis  and  lameness,  the  cartilage 
at  once  passes  back  into  its  place,  and  does  not,  there- 
fore, lock  the  joint.  In  others  it  remains  displaced 
so  as  to  lock  the  joint  until  it  is  set  free,  either  by  some 
accidental  movement,  or  by  manipulation  of  the  limb. 
If  overlooked,  the  displacement  may  remain  for  some 
weeks,  or  even  months.  Many  patients  know  how 
either  to  move  the  limb,  so  as  to  effect  reduction, 
or  to  direct  a  passer-by  to  do  so.  Sometimes  one 
movement  has  the  desired  effect,  sometimes  another. 
The  plan  most  likely  to  succeed  is  to  bend  the  knee  to 
the  fullest  extent ;  a  movement  which,  by  relaxing  all 
the  ligaments,  and  separating  the  articular  surfaces  of 
the  bones  as  far  as  possible  from  each  other,  tends  to 
disengage  the  cartilage;  then  to  freely  rotate  the 
tibia  upon  the  condyles  of  the  femur,  at  the  same  time 
that  the  bones  are  drawn  as  far  as  they  can  be  aj)art, 
and  then  suddenly,  but  not  with  undue  violence,  to 
carry  the  limb  into  full  extension.  During  these 
movements  firm  ])ressure  with  the  thumb  should  be 
made  on  the  cartilage  at  any  point  at  wliich  it  seems 


Displaced  Cartilages. 


259 


over-prominent,  or  where  there  is  tenderness.  Some- 
times reduction  is  effected  with  a  snap,  to  be  distinctly 
felt  or  heard.  In  many  cases  an  anaesthetic  is  highly 
advisable,  or,  indeed,  necessary,  in  order  to  secure 
muscular  relaxation  and  so  limit  the  amount  of  force 
that  is  required  to  extend  the  limb. 

In  these  cases  of  slipping  cartilage  it  is  not  enough 
merely  to  efiect  reduction.  Means  must  be  taken  to 
prevent  a  return  of  the  displacement.  For  this 
purpose,  one  or  other  of  the  clamps  shown  in  Figs. 
60,  61,  will  be  found  extremely  useful.  Fig.  60  shows 
a  light  semicircular 
steel  spring,  passing 
behind  the  joint,  and 
ending  in  two  plates, 
which  embrace  the 
edges  of  the  patella 
and  make  pressure 
on  the  lateral  parts 
of  the  joint.  Fig.  61 
shows  two  jointed 
bars,  one  for  the 
outer  and  one  for 
the  inner  sides  of 
the  joint,  connected 
above  and  below 
with  steel  semicir- 
cles, and  fastening 
above  and  below  the 
patella  with  straps. 
To  either  clamp  a  pad  for  pressure  over  any  part  of 
the  cartilage  that  protrudes  may  be  added. 

In  a  case,  in  which  the  cartilatie  was  torn  across, 
1      •  •  • 

the  joint  remained  useful  after  the  lacerated  disc  had 

been  removed.     This  example,  together  with  others 

that  have  been  recorded,  is  important,  as  showing  that 

the  removal  of  the  semilunar  cartilages  involves  no 


Fig.  60.— Clamp  for  cases  of  Displaced 
Cartilage. 


26o  Manual  of  Surgery. 

material  impairment  of  the  function  of  the  joint. 
Such  an  operation,  however,  can  be  very  seldom 
required,  and  ought  never  to  be  undertaken  until 
all  other  means,  especially  the  use  of  the  clamps 
described  above,  modified  according  to  tlie  case,  have 
been  tried  and  have  failed.  In  instances  in  which 
displacement  has  followed  recently  on  an  injury,  or 
relaxation  of  the  attachments  of  the  cartilages  re- 
sulting from  recent  synovitis,  the  use   of  the  clamp 


Fig.  61.— Clamp  for  Cases  of  Displaced  Cartilage. 

may  be  discontinued  after  from  three  or  six  montlis 
to  a  year.  In  some  cases,  however,  it  must  be  per- 
manently worn.  Many  patients  find  themselves  able, 
when  wearing  the  clamp,  to  play  tennis  or  take  any 
form  of  active  exercise  without  recurrence  of  the  slip. 
In  those  rare  cases  in  which  lepeated  attempts  have 
failed  to  secure  reduction,  the  joint  will  gradually 
acquire  fairly  free  movement  as  the  cartilage  adapts 
itself  to  its  new  position. 

Tumours  of  Joints. 

Very  important  cases  are    occasionally  met  with 
in  which    the  question    arises    whether    we    have   to 


Tumours  of  Joints.  261 

deal  with  some  inflammatory  or  other  disease  of 
a  joint,  or  with  a  new  growth  in  the  articuhir  end 
of  one  of  the  bones.  Tumours  that  imitate  joint 
disease  most  commonly  involve  the  original  growing 
ends  of  the  bones,  that  is,  the  upper  end  of  the 
humerus  and  tibia,  the  lower  ends  of  the  femur, 
radius,  and  ulna.  Hence  the  question  of  diagnosis 
between  tumours  and  joint  disease  mainly,  though 
by  no  means  exclusively,  concerns  the  shoulder, 
the  wrist,  and  the  knee.  Tumours  near  joints  belong 
generally  to  the  sarcomatous  group ;  some  are  myeloid 
in  structure,  some  round  or  spindle-celled.  Some, 
however,  are  entirely  cartilaginous,  or  sarcomatous  with 
a  large  admixture  of  cartilage.  Some  spring  from  the 
interior  of  the  bone,  while  others,  probably  the 
majority,  are  subperiosteal.  In  the  course  of  their 
growth  they  impinge  upon  iand  at  length  come  to 
occupy  the  cavity  of  the  joint,  and  lead  to  the  entire 
destruction  of  the  synovial  membrane,  ligaments,  and 
cartilages,  as  well  as  the  articular  end  of  the  bone  in 
which  they  have  originated  ;  and  to  wide  displacement 
and  deformity  of  the  joint. 

The  likeness  of  a  new  growth  to  joint  disease  is 
sometimes  so  close  that  great  care  is  required  to  avoid 
an  error  that  may  lead  to  disaster.  This  is  the  case 
when  the  new  growth  is  soft  and  elastic,  and  when  it 
is  seated  in  the  immediate  vicinity  of,  or  has  even 
extended  to,  the  synovial  membrane,  so  that  both  by 
its  position  and  its  consistence  it  may  be  mistaken  for 
a  mere  inflammatory  thickening  of  the  latter  structure  \ 
and  when,  moreover,  as  not  rarely  happens,  the  growth, 
by  interfering  with  the  circulation,  has  led  to  effusion 
into  the  cavity  of  the  joint.  Such  tumours,  which 
are  usually  subperiosteal,  generally  grow  towards  the 
joint  in  the  form  of  fleshy  or  spongy,  ill-defined  or 
flattened  lobes  surrounding  the  bone,  and  merging  im- 
perceptibly into  the  adjacent  soft  structures  ;   or  of 


262  Manual  of  Surgery. 

firm  nodules  closely  abutting  on  the  joint.  The  joint 
diseases  which  they  may  closely  resemble  are  {a)  syno- 
vitis attended  with  some  eifnsion,  but  mainly  character- 
ised by  considerable  pulpy  thickening,  and  induration 
of  the  synovial  membrane  ;  (h)  certain  forms  of  chronic 
rlieumatism  or  osteo-arthritis  with  synovial  effusion, 
and  irregular  nodular  enlargement  of  the  articular  ends 
of  the  bones.  The  main  points  indicating  the  presence 
of  a  new  gi'owth  are  the  following  :  A  new  growth  is 
irregular  and,  as  a  rule,  extends  in  some  directions 
obviously  beyond  the  confines  of  the  joint.  The  shaft 
of  the  bone,  as  well  as  its  mere  articular  border,  is  dis- 
tinctly enlarged ;  the  swelling  at  the  part  most  remote 
from  the  joint  is  often  hard,  nodular,  lobed,or  tuberose  ; 
one  bone  only  is  afiected;  movement  of  the  joint  within 
certain  limits  may  be  free.  Enlargement  is  usually 
rapid  and  continuous,  so  that  in  three  months  the 
disease  has  attained  considerable  size ;  the  lymphatic 
glands  may  be  enlarged.  Pain,  heat,  effusion,  and  dis- 
tension of  the  cutaneous  veins  are  symptoms  on  which 
in  respect  to  diagnosis  little  dependence  should  be 
placed.  In  new  growths  pain  may  be  either  slight, 
moderate,  or  severe ;  heat  of  the  surface  and  general 
rise  of  temperature  may  be  as  marked  as  they  are  in 
mere  inflammatory  joint  disease  ;  the  cutaneous  veins 
are  often  enlarged  and  conspicuous  in  some  forms 
of  synovitis.  Some  guidance  may  be  derived  from 
observing  whether  the  patient  presents  any  evidence 
of  the  strumous  or  of  the  rheumatic  diathesis,  or 
is  suffering  from  disease  of  any  other  joint ;  and  the 
history  of  the  case,  and  of  the  patient's  family,  should 
be  inquired  into.  Should  doubt  remain,  the  disease 
should  be  very  closely  watched,  careful  measurements 
should  be  taken,  and  the  case  should  be  treated  as  if 
the  affection  were  inflammatory,  with  rest  and  well- 
fitting  splints,  or  with  such  remedies  as  the  features  of 
each  particular  case  may  suggest.     It  may  even  be 


Excision.  263 

advisable,  due  care  against  septic  infection  being 
taken,  to  remove  a  portion  of  the  disease  for  micro- 
scopic examination,  so  that  diagnosis  may  be  completed 
and  the  appropriate  treatment  entered  upon  ^vitllout 
delay. 

Treatment.— The  treatment  of  tumours  of  the 
articular  ends  of  the  long  bones  involving  the  joints 
is  laid  down  in  Art.  ii.  Here  it  will  be  sufficient  to 
remark  that  the  choice  must  lie  between  amputation 
of  the  limb,  and  enucleation  of  the  growth  ;  or  in  the 
case  of  the  upper  end  of  the  humerus,  or  the  lower 
extremity  of  the  ulna  or  radius,  excision  of  the  end 
of  the  bone.  The  latter  proceeding  may  be  adopjted 
when  the  tumour  is  either  myeloid  or  cartilaginous,  and 
not  too  extensive  ;  but  in  other  instances  amputation 
should  be  performed.  As  some  uncertainty  usually 
remains,  an  incision  ought  always  to  be  made  into 
the  tumour  before  amputation  itself  is  proceeded 
witL 

The  Question  of  Excision  in  Joint  Disease. 

In  estimating  the  value  of  excision  as  a  means 
of  treating  diseases  of  the  joints  it  is  at  once  ap- 
parent that  the  question,  far  from  turning  on  any 
simple  issue  that  can  be  concisely  stated,  is  one  in 
the  discussion  of  which  several  important  con- 
siderations have  to  be  taken  into  account.  This, 
however,  is  not  always  borne  in  mind.  Some  authori- 
ties are,  as  many  think,  too  ready  to  look  at  excision 
merely  as  a  surgical  operation,  whose  success  is  in 
itself  enough  to  secure  a  verdict  in  its  favour.  But 
the  fact  that  the  wound  will  heal  rapidly,  so  that  the 
patient  will  be  up  and  about  in  a  few  weeks,  is  not 
enough  to  justify  a  lesort  to  such  an  operation  as  the 
excision  of  a  large  joint.  It  must  first  be  shown  that 
there  are  no  means  of  a  less  heroic  kind  that  will 
secure  a  still  better,  or  even  an  equally  good,  result. 


264  Manual  of  Surgery. 

Operations  rest  in  different  cases  on  different  principles. 
Now  the  principle  of  excision  is  the  same  as  that  of 
amputation,  or  the  removal  of  an  eye-ball  or  a  testis. 
That  is,  it  abandons  all  attempt  to  cure  disease,  and 
falls  back  on  the  somewhat  primitive  expedient  of 
cutting  away  the  part  in  which  the  disease  is  placed. 
Although  there  are  many  circumstances  in  which  the 
surgeon  is  driven  to  adopt  this  kind  of  operation  {e.g. 
in  dealing  with  malignant  disease),  it  is  obvious  that 
it  should  be  avoided  whenever,  in  the  interest  of  the 
patient,  it  is  possible  to  do  so. 

It  must  be  remembered  also  that  the  necessity  for 
an  operation  often  depends  on  the  stage  which  surgery 
has  reached.  Many  operations  formerly  called  for 
have,  as  surgery  has  improved,  been  to  a  great  extent, 
or  even  entirely,  set  aside.  Some  thirty  or  forty  years 
ago  the  treatment  of  inflammatory  diseases  of  the  joint 
was  so  little  understood,  that  these  affections  commonly 
went  on  from  bad  to  worse  and  to  the  development 
of  formidable  complications,  until  amputation  of  the 
limb  was  the  only  course  that  remained  for  relieving 
tlie  patient  from  intolerable  suffering,  and  enabling 
him  to  follow  some  occupation,  or  even  for  saving  his 
life.  At  this  period  a  great  advance  was  made  when 
Sir  W.  Fcrgusson  and  others  introduced  excision  as  a 
substitute  for  amputation,  and  endeavoured,  by  re- 
moving the  affected  joint,  to  save  the  remainder  of 
the  limb.  Since  that  time,  however,  our  knowledge 
of  diseases  of  the  joints  has  been  considerably  in- 
creased, the  means  of  forming  an  early  diagnosis  have 
been  attained,  and  the  efficacy  of  early  treatment 
on  the  principle  of  complete  rest  has  been  amply 
demonstrated.  It  has  also  come  to  be  well  known 
that,  if  due  precautions  are  taken,  a  joint  in  which 
suppuration  has  occurred  may  be  freely  oj)ened  and 
drained  as  safely  as  any  other  large  abscess  cavity,  and 
that  in  the  majority  of  cases  thus  treated  the  patient 


Excision.  265 

recovers  with  a  very  serviceable  limb.  Under  these 
circumstances,  it  would,  at  first  sight,  appear  that  the 
necessity  of  resorting  to  any  large  operation,  whether 
amputation  or  excision,  involving  the  sacrifice  of  the 
affected  joint,  had  been  set  aside,  and  that  the  broad 
principle  of  conservative  surgery,  the  cure  of  disease 
rather  than  the  cutting  away  of  the  organ  in  which 
the  disease  is  placed,  would  be  as  applicable  in  the 
case  of  the  joints  as  in  any  other  field  of  practice. 

Arguments  for  excision.  —  There  are,  however, 
three  grounds  on  which  some  surgeons  still  advocate 
the  frequent  resort  to  excision  as  a  means  of  treating 
strumous  joint  disease  :  (1)  that  the  operation  saves 
time ;  (2)  that,  as  tuberculosis  is  present^  recovery 
without  operative  interference  is  very  improbable; 
(3)  that  by  removing  the  structure  in  which  tubercle 
is  deposited,  the  danger  of  general  tuberculosis  is 
averted.  None  of  these  arguments  will  bear  close 
examination. 

1.  In  the  first  place,  the  time  saved  (in  other 
words,  the  rapidity  of  repair  after  excision)  turns 
on  the  period  of  the  disease  at  which  the  opera- 
tion is  performed.  In  many  cases  of  long- 
standing disease,  in  which  the  tissues  have  become 
widely  degenerate,  so  far  from  time  being  saved,  the 
wound  often  never  heals  at  all ;  or  it  heals  only  after 
a  period  (extending  over  many  months,  or  even  over 
two  or  three  years)  that  would  have  much  more 
than  sufficed  for  cure  by  continuous  rest.  In  many 
instances  the  disease  is  entirely  unchecked,  or  con- 
siderably aggravated  by  the  operation.  The  only 
cases  in  which  rapid  healing  can  be  depended  upon 
are  those  in  which  such  sli^fht  changes  have  taken 
place  that  continued  rest  w^ould  certainly  lead  to 
recovery,  and  often  to  the  restoration  of  perfectly 
free  movement  in  the  joint.  Besides,  it  is  obvious 
tljat  rapid   repair   is   not  everything.       If   it   were, 


266  Manual  of  Surgery. 

amputation  ought  to  be  performed  in  many  compound 
fractures,  and  even  for  many  lacerated  wounds. 

2.  To  the  proposition  that  as  tubercle  is  commonly 
present,  recovery  without  operative  interference  is  im- 
prol)able,  the  reply  is,  first,  that  microscopic  investiija- 
tion  shows  that  tubercle  is  often  absent  in  the  eai-ly 
stages  of  tliese  affections  ;  and  secondly,  that  whctlior 
tubercle  is  present  or  absent,  cases  which  are  treated 
by  rest  will,  in  all  but  very  exceptional  instances,  end 
in  recovery,  a  fact  attested  by  the  circumstance  that 
excision  is  scarcely  ever  performed  for  patients  in  the 
middle  or  upper  classes. 

3.  The  view  that  excision  averts  or  largely  di- 
mmishes  the  liability  of  systemic  infection  is  met  by 
the  observation,  first,  that  tubercle  is,  as  already  men- 
tioned, often  absent ;  that  general  tuberculosis  is  rare 
as  a  sequel  of  articular  disease  (page  287);  that  even 
in  cases  in  which  tubercle  is  present,  it  is  impossible  to 
ensure  its  complete  removal  by  excising  the  affected 
joint,  or  to  guard  against  the  existence  of  other  and 
more  active  centres  of  infection  elsewhere,  e.g.  in 
some  part  of  the  lymphatic  system. 

Obvious  drawbacks  to  the  general  resort  to  ex- 
cision are,  first,  that  repair  will  not  take  place  unless 
the  patient  is  in  fairly  good  general  health.  Hence, 
to  secure  what  are  termed  good  results,  the  opera- 
tion must  often  be  performed  early,  that  is,  when 
rest  alone  would  have  sufficed  to  effect  a  cure. 
At  later  stages  the  operation  frequently  entirely 
fails,  the  wound  remaining  unhealed,  suppuration 
continuing,  and  the  case,  unless  amputation  is 
performed,  ending  fatally  by  exhaustion  or  amyloid 
disease.  Secondly,  the  limb  after  excision  is,  as  a  rule, 
much  less  useful,  even  when  favourable  repair  has 
taken  place,  than  after  recovery  without  operation. 
After  excision  of  the  knee  in  patients  under  ten  (and 
the  conditions  for  which   the  advocates  of  excision 


Excision.  267 

employ  tlie  operation,  are  much  more  common  before 
than  after  that  age),  the  limb  is,  in  many  instances, 
so  short  and  deformed  by  gi'adual  yielding  that  it 
is  in  great  part  or  entirely  useless. 

These  remarks,  unavoidably  much  condensed,  are 
not  intended  as  a  sweeping  condemnation  of  excision, 
but  as  supporting  the  view  that  the  operation  is  one, 
even  at  present,  of  very  limited  application,  and  one 
that  is  destined  in  the  future  to  fall  more  and  more 
into  disuse. 

In  the  case  of  the  joints,  as  in  that  of  the  eye,  the 
testis,  and  numerous  other  instances,  true  progress 
lies  in  the  direction  of  cultivating  early  diagnosis, 
in  diffusing  a  knowledge  of  the  great  importance  of 
attacking  disease  before  serious  structural  changes 
have  occurred,  and  in  the  adequate  application  of  the 
principle  of  rest.  When  all  this  has  been  done,  the 
necessity  for  such  a  proceeding  as  excision  will  very 
seldom  arise. 

Cases  adaiAed  for  excision. — In  the  meantime, 
however,  there  are  various  instances  in  which  ex- 
cision should  be  adopted.  These,  in  the  case  of  the 
hip,  are  mentioned  at  page  293. 

In  the  knee,  excision  is  mainly  of  use  in  cases  (a)  in 
which  the  bones  are  in  good  condition,  but  where,  as 
the  result  of  subacute  synovitis  of  long  standing, 
attended  with  relaxation  of  the  ligaments,  so  much 
displacement  has  occurred  that  the  limb  cannot  be 
brought  into  a  serviceable  position ;  (b)  in  which, 
though  displacement  is  limited,  the  synovial  membrane 
is  the  seat  of  extensive  pulpy  degeneration,  a  con- 
dition in  which  repair  is  very  unlikely  to  take  place. 
The  operation  is  not  generally  suitable  when  the 
patient  is  under  five  or  even  seven ;  when  disease  is 
acute ;  when  the  bones  are  extensively  involved ; 
or  when  the  general  health  has  broken  down. 

As    to    the    value    of    excision    in     the     other 


268  Manual  of  Surgery. 

articulations,  the  slioulder  joint  is  comparatively  seldom 
diseased,  it  is  easily  kept  at  rest,  and  shows  a  strong 
tendency  to  gradual  recovery,  it  is  lial)le  to  no  de- 
formity, and  although  the  joint  almost  invariably  be- 
comes stiff,  compensatory  movements  at  the  elVjow 
and  between  the  scapula  and  the  trunk  are  so  free 
tliat  the  limb  remains  useful.  Hence,  excision  is  very 
seldom  either  called  for  or  performed,  and  certainly 
the  limb,  after  it,  is  generally  much  less  serviceable 
than  after  repair  by  continued  rest. 

The  elbow  is,  of  all  the  joints,  that  in  which  ex- 
cision yields  the  best  results.  As  growth  takes  place 
at  the  upper  extremity  of  the  humerus,  and  the  lower 
extremity  of  the  ulna  and  radius,  the  removal  of  the 
elbow  joint  ends  of  these  bones  does  not  materially 
affect  the  length  of  the  limb,  nor  is  length  here  a 
matter  of  much  importance.  If  sufficient  bone  is 
removed  to  prevent  ankylosis,  and  if  the  anconeus 
is  preserved,  free  motion  and  considerable  power  are 
secured  ;  the  amount  of  repair  to  be  effected  is  com- 
paratively small.  •  Yet  even  in  this  instance  it  is 
only  in  cases  that  have  been  utterly  neglected  that 
excision  can  be  necessary  ;  for  if  the  joint  is  kept 
at  rest  and  in  good  position,  the  disease  will  very 
rarely  indeed  become  serious ;  on  the  contrary,  it  will 
undergo  steadily  advancing  repair.  Even  when  suppu- 
ration occurs,  if  the  joint  is  opened  antiseptically, 
provision  made  for  free  drainage,  and  rest  is  continued, 
recovery  will  still,  as  a  rule,  ensue. 

Excision  of  the  wrist  for  disease  is  a  rare  operation, 
generally  attended  with  very  limited  success.  There 
are  but  very  few  cases  in  which  disease  of  this  joint, 
when  adequately  treated  by  rest,  does  not  end  in  re- 
covery, and  the  restoration  of  considerable  or  even  un- 
impaired movement ;  whereas,  after  excision,  the  move- 
ments and  strength  of  the  hand  are  alike  very  seriously 
impaired.     Usually  the  removal  of  any  of  the  carpal 


Amputation  in  Joint  Disease.  269 

bones  that  are  provoking  prolonged  suppuration  is 
better  than  a  systematic  excision. 

In  the  case  of  the  ankle,  as  in.  that  of  the  wrist, 
excision  is  both  rare,  and,  as  a  very  general  rule,  in- 
advisable. In  the  early  stage  disease  readily  yields  to 
treatment  by  continued  rest ;  in  the  later  stage  it  is 
very  rarely  confined  to  the  end  of  the  tibia  and  tibula  ; 
it  much  more  commonly  involves  the  tarsus  al^o,  so  that 
the  astragalus  and  perhaps  some  other  bones  must 
be  removed ;  it  is  difficult  to  perform  the  operation 
without  injuring  surrounding  tendons  and  other  im- 
portant anatomical  structures  ;  repair  is  tedious,  and 
the  limb  is  a])t  to  be  subsequently  less  useful  than 
it  is  after  a  Syme's  amputation  of  the  foot. 

As  to  excisions  in  patients  over  twenty-five,  it 
must  here  suffice  to  say,  that  although  successful 
cases  have  been  recorded,  the  operation  in  the  case 
of  the  hip  and  the  knee  is  so  formidable  to  life  that 
it  cannot  be  generally  recommended.  Amputation  is 
almost  constantly  the  safer  alternative.  In  the  other 
joints,  especially  the  elbow,  excision  may,  in  properly 
selected  cases,  jT^eld  good  results  in  healthy  subjects 
in  whom  disease  is  not  acute,  and  in  whom  the  bones 
are  not  extensively  involved. 

The  Question  of  Amputation   in  Joint  Disease. 

It  has  been  pointed  out  that  inflammatory  affec- 
tions of  the  joints  are  amenable,  in  a  degree  that  was 
entirely  unsuspected  even  a  few  years  ago,  to  appro- 
priate treatment ;  and  the  opinion  has  been  expressed 
that  when,  instead  of  being  allowed  to  advance  until 
serious  structural  changes  have  occurred,  these  diseases 
are  adequately  treated  in  theii*  incipient  period, 
excision  will  fall  almost  entirely  into  disuse.  The 
same  may  be  said  of  amputation  for  joint  disease, 
although  it  will  probably  in  the  future  become  the 
more    common  operation    of   the   t\vo.      As    matters 


270  Manual  of  Surgery. 

at  present  stand,  however,  disease,  in  a  considerable 
number  of  instances,  reaches  an  incurable  stage,  and 
becomes  associated  with  various  complications,  and 
amputation  is  all  that  remains  to  be  done. 

The  grounds  for  resorting  to  the  operation  may  refer 
either  to  the  joint  itself  or  to  the  general  condition  of 
the  patient.  Thus,  in  some  instances  in  which  the  disease 
has  become  so  advanced  that  there  is  no  probability  ol 
repair  by  rest  and  its  accessories,  the  ends  of  the  bones 
are  so  extensively  involved  that  excision  is  inadmissible; 
in  others  copious  suppuration  and  wide  burrowing  of 
matter  through  the  limb  preclude  excision ;  in  acute 
disease,  should  the  question  between  excision  and 
amputation  arise,  amputation,  as  a  rule,  had  better  be 
performed. 

As  regards  the  general  condition  of  the  patient, 
it  must,  as  already  said,  always  be  remembered  that 
satisfactory  repair  after  excision  of  a  large  joint 
will  take  place  only  when  the  patient  is  in  fairly  good 
health.  Hence,  a  state  of  exhaustion  or  feebleness, 
and  the  cachexia  of  advanced  tuberculosis,  are  condi- 
tions which  tend  to  preclude  repair,  or  at  least  to 
render  it  very  doubtful.  In  these  cases,  on  the  other 
hand,  amj^utation  is  usually  followed  by  rapid  recovery. 

The  age  of  the  patient  is  a  very  important  point. 
Subscribing  to  the  great  principle  of  conservatism, 
every  surgeon,  if  his  choice  were  free,  would  prefer 
excision  to  amputation.  Experience,  however,  has 
amply  shown,  that  in  many  cases  amputation  is 
the  better  operation.  In  children  under  five  the 
articular  ends  of  the  femur  and  tibia  are  so  largely 
cartilaginous,  that  firm  union  after  excision  often 
fails  to  take  place.  In  adults,  say  after,  at  the  latest, 
thirty  years  of  age,  the  risks  of  excision  are  so  great, 
and  those  of  amputation  so  comparatively  small, 
that  the  latter  operation  should,  as  a  rule,  be 
performed.     In  dealing  with  the  advanced  forms  of 


Disease  of  Shoulder  Joint.  271 

joint  disease,  it  is  very  important  not  to  misjudge  the 
case  so  as  to  allow  the  period  at  which  amputation 
would  succeed  to  pass  by. 

The  grounds  for  resorting  to  the  operation  without 
further  delay  have  reference  chiefly  to  the  patient's 
general  condition.  So  long  as  this  is  not  unfavour- 
able, expectant  treatment  by  rest,  etc.,  may  be 
persevered  in ;  but  should  it  be  found  that  the 
patient  is  steadily  losing  appetite  and  strength,  that 
he  is  also  losing  flesh  (always  a  highly  impoi-tant 
point),  that  the  temperature  remains  high,  that  sweating 
is  copious,  and  that  the  pulse  is  becoming  smaller  and 
more  rapid,  further  delay  is  dangerous.  Especially 
in  these  cases  must  a  watch  be  kept  for  the  appearance 
of  albumen  in  the  urine,  and  for  enlargement  of  the 
liver,  as  evidence  that  amyloid  degeneration  of  the 
viscera  has  commenced.  Formerly  it  was  supposed 
that  this  condition  precluded  operative  interference, 
but  it  is  now  well  known  that  if  the  suppuration 
on  which  it  depends  can  be  arrested,  this  complication 
will  generally  disappear.  This  is  the  case,  however, 
only  when  amyloid  degeneration  is  of  recent  date. 
When  it  is  of  long  standing,  not  only  is  it  irremedi- 
able, but  it  is  extremely  likely  to  determine  a  fatal 
result  if  amputation  is  performed. 

Diseases  of  Individual  Joints. 

^\\^\\\Ae,v*— Strumous  affections  of  the  shoulder 
joint  are  common  in  childhood  and  early  adult  life. 
Disease  may  begin  either  as  synovitis,  the  most  usual 
form,  or  as  epiphysitis  of  the  humerus,  soon  extending 
to  the  joint  itself.  In  either  case  the  aflection  is 
generally  subacute  ;  often  so  insidious  that  it  is  apt  to 
be  overlooked.  Pain  is  often  absent,  or  very  slightly 
marked ;  it  is  felt  in  or  around  the  joint,  or  near  the 
insertion  of  the  deltoid.  The  most  prominent  symp- 
toms are  wasting  of  the  deltoid  and  of  the  scapular 


272  Manual  of  Surgery. 

muscles,  and  stiffness  of  the  joint,  the  scapula  following 
the  humerus  both  when  the  patient  moves  the  arm, 
and  when  an  attempt  is  made  to  rotate  the  humerus 
in  the  glenoid  cavity.  The  arm  remains  at  the  side, 
and  no  deformity  is  produced.  Suppuration  is  rare,  but 
in  epiphysitis  abscess  may  form  beneath,  and  at  length 
point  at  the  anterior  border  of  the  deltoid,  or  in  the 
axilla.  The  shoulder  is  so  easily  kept  at  rest,  its 
movements  being  so  readily  performed  between  the 
scapula  and  the  thorax,  and  at  the  elbow,  that  disease 
of  the  joint,  though  it  may  be  tedious,  shows  a  marked 
tendency  to  recovery.  Treatment  consists  in  main- 
taining rest  by  keeping  the  arm  bandaged  to  the  side  ; 
and  if  it  is  thought  necessary,  a  leather  shield  splint 
may  be  moulded  to  the  joint  and  upper  half  of  the 
arm.  Even  in  early  cases  rest  should  be  continued 
for  at  least  three  or  four  months.  If  abscess  forms 
it  should  at  once  be  opened  antiseptically.  In 
epiphysitis  necrosis  is  rare,  and  operative  interference 
is  seldom  required.  Should  a  sinus,  however,  remain 
unclosed,  in  spite  of  continued  rest  of  the  joint,  it 
should  be  carefully  explored.  If  a  sequestrum  is 
detected  it  should  be  removed,  but  generally  no  carious 
or  inflamed  bone  should  be  gouged  away. 

As  the  result  even  of  slight  disease  this  joint 
usually  remains  stiff,  and  the  question  of  endeavouring 
to  restore  movement  by  manipulation  presents  itself. 
The  necessity  of  interference  after  mere  sprains  or 
contusions  is  now  well  understood  ;  but  when  stiffness 
has  followed  disease  manipulation  will  veiy  seldom 
be  attended  with  benefit,  while  it  will  often  be  in- 
jurious by  provoking  a  return  of  inflammatory  action. 
This  is  especially  the  case  in  strumous  disease. 

Acute  arthritis  is  common  in  this  joint  in 
infants  under  two.  As  its  result,  a  large  collection 
of  matter  is  rapidly  formed  beneath  the  deltoid, 
sometimes    extending    forward    under    the    pectoral 


Disease  of  Elbow  Joint.  273 

muscles  as  well  as  into  the  axilla.  The  upper 
end  of  the  humerus  is  often  completely  destroyed, 
and  with  the  loss  of  the  epiphysis  the  subsequent 
growth  of  the  bone  is  arrested,  and  the  arm  may  ulti- 
mately be  three  or  four  inches  shorter  than  its  fellow, 
and  remain  weak  and  flail-like.  Treatment  consists 
in  the  early  evacuation  and  free  drainage  of 
matter,  and  in  supporting  the  strength  of  the  patient 
by  the  means  already  described  (page  240).  In 
pycemia  and  septicannia  the  shoulder  is  often  the 
seat  of  the  rapid  formation  of  a  large  abscess,  which 
gives  the  joint  a  globular  or  rounded  outline.  Fluc- 
tuation is  very  distinct.  In  some  instances,  how- 
ever, effusion  is  merely  serous,  and  may  undergo 
absorption.  Charcots  disease  and  osteo-arthritis  are 
common  in  the  joint.  In  the  latter,  the  articulation 
becomes  stiff  and  painful  ;  cracking  or  grating  is 
felt  on  movement,  muscular  wasting  is  marked ; 
and  pain  of  a  dull  aching  or  gnawing  character  is 
complained  of  either  in  the  joint  itself  or  the  outer 
part  of  the  arm  beneath  the  deltoid.  As  the  disease 
advances  the  articular  surfaces  become  altered  in 
outline,  and  the  head  of  the  humerus,  enlarged  by 
osteophytic  growths  around  its  margin,  is  found  to  be 
displaced  upwards  and  forwards  so  as  to  imitate  the 
appearance  of  subcoracoid  dislocation.  This  should  be 
borne  in  mind,  and  in  any  case  of  obscure  injury  of 
tlie  shoulder  in  an  elderly  person  careful  inquiry 
should  be  made  into  the  previous  condition  of  this 
joint  before  any  step  is  taken  to  effect  the  reduction  of 
what  at  first  sight  may  be  erroneously  mistaken  for  a 
recent  dislocation.  For  the  treatment  of  osteo-arthritis 
see  page  278.  Si/plnlitic  disease  of  this  joint  is 
extremely  rare  (page  224).  I  have  never  met  with, 
any  instance  of  it. 

The    elbow. — Strumous  disease,  both  in  the  form 
of  synovitis,   and   of  osteitis,  beginning  either  in  the 
S— 21 


2  74  Manual  of  Surgery, 

articular  end  of  the  humerus  or  the  ulna,  is  of  very 
frequent  occurrence.  The  joint  is  more  or  less,  but 
sometimes  very  slightly,  restricted  in  its  various 
movements  ;  puffy  swelling,  especially  over  the  head  of 
the  radius  and  by  the  sides  of  the  tendon  of  the 
triceps  (giving  the  joint  an  appearance  of  increased 
width  when  viewed  from  behind)  is  well  marked ; 
there  is  often,  but  by  no  means  invariably,  increased 
heat  of  the  surface  ;  muscular  wasting,  especially  of  the 
arm,  is  a  constant,  often  a  very  early,  symptom.  The 
disease  is  generally  chronic,  but  it  may  be  acute,  and 
pass  on  quickly  to  the  formation  of  matter,  distending 
the  synovial  membrane  and  pointing  either  at  the 
outer  or  inner  aspect  of  the  joint.  Pain  is  seldom  a 
marked  symptom,  and  is  often  so  entirely  absent  that 
parents,  and  even  the  surgeon,  may  be  misled.  Stiff- 
ness, puffy  swelling,  and  muscular  wasting,  are,  in  fact, 
the  most  reliable  symptoms.  Treatment  consists  in 
the  use  of  well-fitted  leather  splints,  confining  the 
joint  at  a  right  angle  (Fig.  52),  the  arm  being  kept 
in  a  sling.  Matter,  if  any  form,  must  be  evacuated, 
a  "window"  being  cut  in  the  splint  to  allow  of 
di'ainage.  Though  stiffness  sometimes  remains  when 
inflammation  is  plastic,  perfectly  free  movement  is 
often  regained  when  treatment  has  been  applied 
early  and  has  been  sufiiciently  prolonged.  The 
splints  must  be  continued  for  from  three  months 
to  nine  months,  or  even,  in  older  cases,  for  a  year  or 
more.  When  the  articular  ends  of  the  bones  are 
carious  it  is  useless  to  gouge  away  the  inflamed  struc- 
tures. With  rest  the  osseous  tissue  will  very  usually 
regain  a  healthy  condition  ;  but  this  failing,  or  where 
the  extensively  diseased  synovial  membrane  continues 
to  suppurate  in  spite  of  long-continued  rest,  excision 
will  be  indicated. 

Acute   arthritis   of    infants    is   frequent    in    the 
elbow.      The  joint,  often  within  two  or  three  days, 


Disease  of    Wkist  Joint.  275 

becomes  the  seat  of  a  large  abscess,  and  the  ar- 
ticular ends  of  the  bones,  as  well  as  all  the  ligamen- 
tous structures,  are  rapidly  destroyed,  so  that  the 
humerus  and  bones  of  the  fore-arm  are  widely  movable 
in  all  directions  on  each  other.  In  early  cases,  if 
matter  is  at  once  evacuated,  this  extensive  destruction 
may  be  avoided,  and  the  joint  may  regain  all  its  nor- 
mal movements,  while  in  cases  in  which  treatment  has 
been  neglected  the  joint  remains  weak,  loose,  and 
flail-like.  The  elbow  is  a  common  seat  of  Charcofs 
disease,  and  often  presents,  in  a  characteristic 
form,  the  changes  induced  by  this  affection.  The 
joint  becomes,  sometimes  very  rapidly,  enlarged  and 
deformed  by  the  accumulation  of  fluid  in  the  interior, 
and  in  adventitious  periarticular  bursal  sacs ;  and  also 
by  the  destruction  of  the  articular  surfaces  of  the  bones 
and  the  heaping  up  of  irregular  osteophytic  masses 
about  the  ends  of  the  shafts.  The  joint  admits  of  ab- 
normally free  motion  and  coarse  gi'ating  is  felt.  There 
is,  however,  little  or  no  pain,  and  the  patient  uses  the 
limb  freely.  Osteo-arthritis  often  involves  this  joint, 
though  less  frequently  than  it  does  the  knee,  hip,  and 
shoulder.  The  usual  symjitoms  of  slowly  increasing 
stiflhess,  pain  of  a  dull  wearing  character,  cracking 
and  creaking  on  movement,  together  with  the 
presence  of  the  disease  in  other  joints,  frequently, 
among  the  rest,  in  the  opposite  elbow,  will  render 
diagnosis  very  easy.  For  treatment  see  page  278.  In 
the  course  of  pi/ceynia  and  other  forms  of  blood  poison- 
ing, the  elbow  (an  articulation,  however,  which  often 
escapes)  presents  lesions,  the  features  and  treatment 
of  which  have  been  described  (page  227).  Syphilitic 
disease  of  the  elbow  joint  is  not  rare,  and  probably 
many  instances  of  chronic  and  relapsing  inflamma- 
tion in  adults,  attended  with  thickening  of  the  synovial 
membrane  and  not  yielding  to  the  prolonged  use  of 
rest,  have  been  of  this  character  (page  224:) 


276  Manual  of  Surgery. 

^Wx\%\, — In  children  and  young  adults,  and  even 
occasionally  in  old  persons  (page  248),  strumous  affec- 
tions are  prone  to  attack  this  joint,  which  becomes 
slightly  flexed,  swollen,  and  pufly,  both  on  the  dorsal 
and  palmar  aspects ;  normal  depressions  between  the 
tendons  are  lost,  and  the  part  assumes  a  smooth  fusi 
form  outline,  the  result  of  synovial  thickening.  A 
well-marked  feature  is  impairment  of  the  movements 
of  the  hand,  especially  of  pronation  and  supination ; 
and  the  power  of  grasping  objects  firmly  is  lost. 
Muscular  wasting  of  the  fore-arm  is  always  present ; 
pain  and  surface  heat  are  very  variable  symptoms ; 
they  are  often  absent  in  cases  in  which  the  joint  is  in 
a  state  of  advanced  disease.  Treatment. — The  joint 
must  at  once  be  enclosed  in  leather  splints  {see 
Fig.  53),  and  the  fore-arm  supported  in  a  sling,  the 
patient  being  forbidden  to  make  any  use  of  the 
limb.  Cases  are  very  rare  in  which  recovery  will 
not  follow,  if  this  plan  is  adopted  early  and  continued 
for  the  necessary  period  of  from  three  to  six  months. 
In  advanced  cases  the  time  must  be  extended  to  a 
year,  or  even  longer.  If  suppuration  occurs,  matter 
should  be  evacuated,  and  drainage  provided  for.  When, 
in  spite  of  three  or  four  months  of  rest,  suppuration 
continues  to  be  free,  it  should  be  ascertained,  with 
as  little  disturbance  of  the  structui-es  as  possible, 
whether  any  of  the  carpal  bones  have  become  necrosed 
and  loose.  If  any  are  so  found  they  should  be  re- 
moved ;  but  if  the  bones  are  merely  inflamed,  or  in 
a  state  of  caries,  they  should  be  left  for  repair  by  a 
still  longer  period  of  rest ;  for  here,  as  in  all  other 
cases,  the  gouging  away  of  inflamed  or  caiious  bone 
will  have  the  effect  of  aggravating  rather  than  of 
removing  the  disease.  In  cases  of  extensive  disease 
some  surgeons  resort  to  a  systematic  excision  of  the 
wrist  joint.  Very  generally,  however,  a  better  result 
will   be   obtained   by   long-continued  rest,   combined 


Hip   Disease.  277 

with  the  removal  of  any  sequestra  that  are  from  time 
to  time  found  to  be  loose.  It  is  difficult,  without  ex- 
perience, to  credit  the  amount  of  repair  that  will 
follow  this  treatment  by  rest  pei-severingly  maintained. 
Osteo-arthritis  frequently  attacks  this  joint,  which 
becomes  stiff,  particularly  as  regards  pronation  and 
supination,  and  painful ;  swelling,  usually  slight,  in 
some  instances  becomes  considerable,  as  the  result  of 
ganglionic  enlargement  involving  the  sheaths  of  the 
flexor  and  extensor  tendons.  Such  cases  are  always 
tedious,  but  much  good  may  sometimes  be  done  by 
placing  the  limb  in  splints,  carefully  evacuating  any 
large  collections  that  may  have  formed,  by  antiseptic 
[juncture,  blistering  the  joint  for  five  or  six  weeks,  and 
tlien  applying  Martin's  -indiarubber  bandage,  to  secure 
uniform  pressure.  In  the  management  of  yycemic  and 
other  forms  of  blood  poisoning,  affecting  the  wrist,  the 
main  points,  locally,  are  the  support  of  the  joint  so  as 
to  prevent  deformity,  and  the  early  antiseptic  evacua- 
tions of  matter.  Syphilitic  disease  of  this  joint  ap- 
pears to  be  very  rarely  met  with.  I  have  never  seen  it. 
Hip. — The  remarkable  features  of  GJiarcofs  disease 
of  the  hip  are  detailed  in  Art.  xxix.,  vol.  i.  Osteo- 
arthritis of  this  joint  was  formerly  designated  morbus 
coxae  senilis,  or  from  the  fact  that,  especially  in 
males,  the  hip  is  often  the  only  joint  attacked. 
Monarticidar  rheumatism. — The  affection  commences, 
usually  in  persons  over  forty-five  (thougli  it  may 
be  met  with  earlier),  with  j>ain  about  the  joint,  or 
at  the  back  of  the  thigh  in  the  course  of  the  sciatic 
nerve,  or  in  the  neighbourhood  of  the  knee  ;  gradually 
increasing  lameness  and  stiffness,  so  that  the  patient  is 
unable  to  stoop  or  dress  himself ;  and  wasting  of  the 
muscles  of  the  thigh  and  hip.  As  the  disease  advances 
all  the  symptoms  become  more  pronounced.  Pain  is 
often  constant  and  severe.  The  limb  becomes  gradu- 
ally shortened    and    everted,  and   on  examination  it 


278  Manual  of  Surgery. 

is  found  that,  as  the  result  of  absorption  of  the  upper 
border  of  the  acetabulum  and  head  of  the  femur,  the 
trochanter  has  become  displaced  so  as  to  lie  considerably 
above  Nelaton's  line  (page  283) ;  shrinking  of  the  limb 
continues,  and  lameness  becomes  extreme.  These  cases 
are  often,  in  their  early  stage,  mistaken  for  sciatica. 
A  correct  diagnosis,  however,  can  at  once  be  made  ])y 
testing  the  movements  of  the  hip.  Treatment. — The 
patient  should  wear  flannel  over  the  joint,  so  as  to  secure 
warmth  at  a  uniform  temperature,  and  should  take 
moderate  exercise.  Complete  rest  promotes  stiffness. 
Blisters  and  liniments  of  opium  and  belladonna  often 
diminish  pain.  Hot  fomentations  and  douching  give  re- 
lief, and  many  patients  find  great  benefit  from  the  hot 
douche  treatment  at  Buxton,  Harrogate,  Wildbad, 
Baden,  or  Aix-les-Bains.  If  r.rates  or  deposits  of  uric 
acid  are  present  in  the  urine,  five  grains  of  the  citrate 
of  lithia  should  be  given  once  or  twice  daily  in  potash 
water.  Usually  the  limb  remains  in  a  position  of  exten- 
sion, and  no  splints  or  other  mechanical  appliance  are  of 
any  service.  Occasionally  by  manipulation,  under  an 
anaesthetic,  motion  may,  for  a  time,  be  increased  by 
the  detachment  of  osteophytes  around  the  joint  and 
the  rupture  of  adhesions,  but,  as  a  rule,  forcible 
movement  aggravates  rather  than  improves  the  con- 
dition of  the  limb,  and  it  should  not,  therefore,  be 
adopted  without  careful  consideration.  Acute  injlani. 
mation  of  the  hip  joint,  developed  in  the  course  of  jjy- 
cemia  and  other  kinds  of  blood  poisoning,  is  formidable 
in  the  highest  degree.  Pain  is  usually  very  severe,  the 
joint  quickly  becomes  disorganised,  and  the  patient 
is  threatened  with  death  by  exhaustion.  The  joint 
must  be,  at  the  very  outset  of  the  disease,  placed 
at  rest  by  the  application  of  a  weight  to  the  foot,  com- 
bined with  the  use  of  a  Thomas's  splint,  or  of  an 
interrupted  long  splint,  and  matter  should  be  evacu- 
ated, either  by  the  aspirator  or  by  antiseptic  incision, 


Hip   Disease,  279 

and  free  drainage  be  provided.  In  young  subjects, 
should  other  conditions  be  favourable,  amputation 
may  sometimes  be  performed  ;  but  in  adults  this  step 
generally  cannot  be  ventured  upon.  In  the  coui'se  of 
typhoid  fever  the  hip  (apparently  more  often  than 
any  other  joint)  is  liable  to  be  attacked  with  inflam- 
mation, attended  with  the  same  symptoms  as  are 
met  with  in  ordinary  hip  disease.  The  affection  is 
usually  subacute,  and  rarely  goes  on  to  suppuration  ; 
serous  effusion,  however,  is  often  considerable,  and 
spontaneous  dislocation  is  apt  to  occur.  In  any  case, 
therefore,  should  the  patient  complain  of  pain,  careful 
examination  should  at  once  be  made,  and  if  the  joint 
is  found  stiff  and  sensitive  on  movement,  weight  exten- 
sion should  be  applied  (page  287),  the  limb  should  be 
supported  between  sand-bags,  and  a  cradle  placed  over 
the  foot  to  prevent  pressure  by  the  bed  clothes. 

In  gonorrhceal  rlieumatism  the  hip  is  veiy  liable  to 
be  affected.  The  symptoms  are  those  of  an  acute  or 
subacute  and  very  persistent  inflammation,  which 
often  leaves  the  limb  completely  fixed  by  adhesions 
within  and  around  the  joint.  Suppuration,  though  very 
rare,  is  occasionally  met  with.  In  its  active  stage  the 
case  must  be  treated  on  the  plan  given  at  page  287. 
Subsequently,  in  order  to  restore  movements,  manipula- 
tion, under  an  anaesthetic,  followed  by  hot  douching, 
shampooing,  and  passive  movements,  and  repeated,  if 
necessary,  at  the  end  of  a  fortnight  or  three  weeks, 
will  be  required.  These  means  will  often  succeed, 
but  no  undue  violence  must  be  used;  nor  should  forcible 
movement  be  persisted  in  if  it  is  followed  by  severe 
pain  that  does  not  quickly  subside,  or  by  marked 
swelling  about  the  joint. 

Strumous   Disease  of  the   Hip  Joint. 

This  affection  presents  so  many  special  features  as 
regards  its  symptoms  and  diagnosis,  the  course  it  takes, 


28o  Manual  of  Surgery. 

and  tlie  treatment  it  requires,  that  it  is  convenient 
to  describe  it  under  a  separate  name.  It  must,  how- 
ever, be  understood,  that  it  diflbrs  in  no  material 
respect  from  those  chronic  diseases  of  the  other  joints, 
which  are  generally  regarded  as  strumous  or  scrofulous. 

Although  met  with  at  any  age  up  to  puberty, 
and  occasionally  in  middle  and  even  in  advanced 
life,  hip  disease  most  frequently  begins  in  child- 
hood between  the  ages  of  three  and  seven.  It  origi- 
nates most  commonly  in  the  bones,  i.e.  in  the  upper 
end  of  the  femur,  or  in  the  floor  of  the  acetabulum. 
The  frequency  of  disease  in  these  structures  is  pro- 
bably due  to  the  fact  that,  being  centres  of  rapid 
growth,  their  nutrition  is  unstable,  and  apt,  on  any 
disturbance,  to  pass  into  inflammatory  action  ;  and  it 
is  easy  to  see  that  as  these  parts  themselves  are  within 
the  capsule,  disease  in  them  must  almost  inevitably 
provoke  a  general  arthritis.  In  a  certain  number  of 
cases  disease  commences  in  the  synovial  membrane. 
The  view  formerly  held,  that  it  had  its  starting  point 
in  the  ligamentum  teres,  or  in  the  articular  cartilage, 
is  now  known  to  have  been  erroneous. 

Synovial  cases,  though  they  are  sometimes  acute, 
generally  take  a  mild  course,  yield  readily  to  treat- 
ment in  their  early  stage,  and  often  end,  though 
conval(!Scence  is  tedious,  in  complete  lecovery.  Cases 
in  which  the  bones  are  afFectod  are  much  more  serious. 
If  carefully  treated  they,  like  the  synovial  form,  end 
in  satisfactory  recovery,  though  this  may  be  long 
delayed.  But  when  neglected  they  pass  on  to  caries 
or  necrosis,  supjiuration,  and  great  deformity,  and 
frequently  to  a  fatal  result. 

I>iag°iiosis. — Well-established  hip  disease  may 
be  recognised  almost  at  a  glance;  but  in  the  early 
period,  when  it  is  so  highly  important  to  form  a  cor- 
rect opinion,  diagnosis  is  often  attended  with  great 
difficulty,  first  because  the  symptoms  are  very  slightly 


Hip   Disease.  281. 

marked,  and,  secondly,  because  almost  all  the  indi- 
vidual symptoms  of  hip  disease  are  also  the  symptoms 
of  disease  either  of  the  spine,  or  of  some  neighbouring 
part.  Hence,  a  correct  oi)inion  can  be  reached  only 
by  observing  and  comparing  a  number  of  slight  signs, 
any  one  of  which  alone  would  be  quite  inconclusive. 

Syinptoms. — These  will  be  stated  in  the  order  in 
which  they  would  present  themselves  in  an  actual  case  : 

1.  Lameness  is  always  present,  but  it  may  be  so 
slight  that  it  is  easily  overlooked.  It  is  due  to  the 
fact  that  the  joint  is  either  in  a  stiff  or  distorted 
condition,  or  is  too  sensitive  to  bear  any  weight. 
There  is,  however,  no  form  of  lameness  that  is  in 
the  least  degree  characteristic  of  kip  disease.  The 
symptom  must  always  be  studied  in  conjunction  with 
other  evidences  of  the  disease. 

2.  Fain. — This  is  very  variable  both  in  degree  and 
situation.  Sometimes  it  is  so  slight,  or  entirely 
absent,  that  the  disease  is  not  suspected.  Sometimes 
it  is  severe  from  the  first.  It  may  be  in  the  joint 
itself,  or  transferred  to  the  nerve  peripheries,  and  so 
be  felt  either  in  the  knee  or  the  inner  side  of  the 
thigh  or  the  leg.  It  must,  however,  be  borne  in  mind 
that  pain  may  be  referred  to  these  situations  in  several 
other  diseases,  as  of  the  lumbar  spine  or  the  sacro-iliac 
joint,  cancer  of  the  rectum,  and  abscess  or  aneurism 
in  Scarpa's  triangle;  in  any  case,  in  fact,  in  which  the 
trunk  or  higher  branches  of  either  the  obturator  or 
anterior  crural,  which  both  supply  the  hip  joint,  are 
iriitated. 

3.  Altered  position  of  the  liiuh. — In  a  typical  case, 
in  the  early  period  of  disease,  the  joint  is  liexed,  ab- 
ducted and  rotated  outwards.  Many  theories  have 
been  advanced  to  explain  this  position.  It  is,  how- 
ever, merely  that  of  greatest  ease,  and  that  which  we 
unconsciously  adopt  as  we  sit  at  rest  with  the  limbs 
flexed  on  the  trunk,  the  knees  apart,  and  the  heels 


282 


Manual  of  Surgery. 


touching.  This  position  relaxes  all  the  ligaments  of  the 
joint.  Thus,  flexion  relaxes  the  front  of  the  capsule, 
abduction  the  Jigamentum  teres  and  the  outer  band  of 
the  ilio-femoral  ligament,  rotation  outwards  the  inner 
band  of  this  ligament  and  the  back  of  the  capsule. 

This  position  of  the  limb,  however,  is  generally 
not  at  once  obvious  when  we  examine  the  patient.  In- 
stead of  it  we  find  that  the  diseased  limb  is  extended, 
and   parallel  with  its   fellow,  that   tlie  lumbar  spine 

is  arched  forward  (lordosis), 
that  the  pelvis  is  dej)ressed 
on  the  affected  side,  and  that 
the  limb  looks  longer  than  its 
fellow.  This  attitude  is  thus 
explained.  Obviously  a  limb 
that  is  fixed  in  a  position  of 
flexion  and  abduction  (which, 
in  other  words,  is  pointed  for- 
wards and  outwards)  is  useless 
for  progression  (Fig.  62).  To 
overcome  this  difficulty,  the 
patient,  by  curving  the  lumbar 
spine  forwards,  rotates  the 
pelvis  on  its  transverse  hori- 
zontal axis,  and  so  makes  the  femur  point  down- 
wards instead  of  forwards ;  and  by  curving  the 
lumbar  spine  laterally,  so  that  the  pelvis  is  raised 
on  the  sound  and  depressed  on  the  affected  side,  he 
brings  the  femur  inwards  towards  the  middle  line 
(Fig.  G3).  The  apparent  lengthening  of  the  limb  is 
due  merely  to  the  fact  that  the  pelvis  on  that  side 
is  depressed  ;  in  otlier  words,  apparent  lengthening 
always  indicates  that  the  limb  is  abducted.  As  to 
real  lengthening  of  the  limb  this  probably  never 
occurs.  I  have  never  recognised  an  instance  of  it.  In 
the  later  period  of  disease,  the  powerful  adductors, 
under  the   influence    of   reflex    irritation,    draw    the 


Fig.  62. 


Hip  Disease. 


283 


i^HB^^^Hai 


Fig. 63. 


limb  inwards  so    that    it    now   becomes    flexed    and 

adducted,  instead   of  flexed  and  abducted   (Fig.   64). 

Here,  again,   the  limb  occupies   a  position   (crossing 

the  opposite  thigh)  in  which    it   is 

useless.     To  meet  the  difficulty  the 

patient  curves  his  spine  laterally  so 

as  to  draw  up  the  affected  side,  and 

so  brings  the  femur  outwards,  till  it 

is  again  parallel  with  its  fellow,  witJi 

the    result,    however,    of   producing 

apparent    shortening    of    the    limb 

(Fig.  Go).     Thus  apparent  shortening 

always  dej^ends  on  adduction.     At  a 

still  later  period  the  limb  undergoes 

real  shortening  as  the  upper  border 

of  the  acetabulum  and  the  head  of 

the  femur  become  absorbed,  and  the 

trochanter    is    carried    upwards    by 

muscular  action,  more  or  less  above  Nelaton's  line 
(drawn  from  the  anterior  iliac  spine 
to  the  tuberosity  of  the  ischium). 
Another  cause  of  real  shortening  is 
arrest  of  growth  of  the  limb. 

4.  Loss  of  jiiovement  in  the  joint 
is  the  most  constant  and  the  most 
reliable  sign  of  hip  disease.  Even 
in  the  very  earliest  stage  some  loss 
of  motion  is  so  constantly  present 
that  completely  free  movement  is  in 
itself  almost  enough  to  prove  that 
the  joint  is  sound.  Various  condi- 
tions, however,  it  must  be  remem- 
bered, may  interfere  with  flexion  and 
extension  of  the  thigh  on  the  trunk, 

e.g.  psoas  abscess  will  often  prevent  full  extension, 

while  abscess  under  the  glutei   will  limit  flexion.      It 

is  necessary,  therefore,  to  ascertain  whether,  when  the 


Fig.  64. 


284 


Manual  of  Surgery. 


limb  is  semiflexed,  the  femur  will  rotate  freely  in  the 
acetabulum.  If  the  ball-and-socket  movement  is  free, 
it  may  be  concluded  that  the  loss  of  flexion  and  ex- 
tension is  due  to  some  impediment  outside  the  joint, 
but  if  rotation,  as  well  as  the  other  movements,  is 
lost  or  distinctly  impaired,  it  must  be  concluded  that 
the  joint  itself  is  diseased. 

5.  Muscular  loastimj^  always  an  important  symp- 
tom, due  mainly  to  reflex  atroj)hy,  but  in  part  to 
disuse,  is  constantly  present  in  estab- 
lished disease,  and  may  even  be  well 
marked  in  three  or  four  weeks.  It 
shows  itself  as  flattening  of  the  hip 
and  loss  of  the  fold  at  the  lower 
border  of  the  gluteus,  and  also  by 
shrinking  of  the  thigh,  accompanied 
by  a  flabby  condition  of  the  muscles, 
detected  by  measuring  the  two  limbs 
at  the  same  level. 

6.  Swelling. — This  may  be  due 
to  general  fulness  about  the  joint, 
perhaps  with  enlargement  of  the 
glands  in  Scarpa's  triangle,  and  to 
the  presence  of  abscess,  which  may 
be  found  at  any  aspect  of  the  articulation. 

For  examination  the  patient  must  be  undressed, 
and  lying  on  some  firm  surface,  so  that  the  real 
position  of  the  limb  can  be  made  out.  The  surgeon 
must  see  whether  the  knee  can  be  brought  down 
without  producing  anterior  curvature  of  the  lumbar 
spine  (lordosis) ;  whether  the  heels  are  level ;  and 
whether  the  anterior  iliac  spines  are  horizontal.  If 
when  the  knee  is  down  the  spine  is  curved  forward,  it 
shows  that  the  thigh  is  flexed.  The  amount  of  flexion 
will  be  disclosed  by  raising  the  knee  till  the  spine  is 
straight.  If  the  iliac  spine  on  the  suspected  side  is 
depressed  {see  Fig.   63),  it  indicates  that  the  limb  is 


Fig.  65. 


Hip  Disease.  285 

abducted,  and  the  degree  of  abduction  will  be  shown 
by  carrying  the  limb  outwards  till  the  iliac  spines  are 
restored  to  the  same  level.  If,  however,  the  iliac  spine 
of  the  suspected  side  is  drawn  up  (Fig.  65),  it  indicates 
adduction,  the  amount  of  which  will  be  brought  out 
by  adducting  the  limb  till  the  pelvis  is  again  hori- 
zontal. The  real  position  of  the  limb  will  thus  be 
ascertained.  Flexion,  and  extension  of  the  thigh  on  the 
trunk,  and  rotation  of  the  femur  in  the  acetabulum 
should  now  be  investigated.  This  test  must  be  very 
gently  applied,  but  each  movement  must  be  carried  to 
its  full  natural  range,  for  it  is  only  when  the  extreme 
limits  are  approached  that  slight  restrictions  of  move- 
ment become  apparent.  Muscular  wasting  of  the  limb 
and  swelling  about  the  joint  should  next  be  looked  for. 
Sometimes  when  the  joint  is  grasped  from  before  back- 
wards, between  the  finger  and  thumb,  enlargement  of 
the  upper  end  of  the  femur  will  be  detected.  Tenderness 
on  carefully  applied  pressure,  either  in  front  of  or  behind 
the  joint,  is  sometimes  a  marked  symptom.  Jarring 
of  the  heel  or  knee  is  a  worthless  test.  It  often 
makes  a  timid  child  shrink,  though  the  joint  is  per- 
fectly sound,  while  often  it  causes  no  uneasiness, 
although  hip  disease  is  well  marked. 

When  these  various  signs  have  been  investigated 
a  conclusion  is  generally  readily  formed  ;  but  some- 
times early  diagnosis  must  rest  on  two  or  three  slight 
yet  distinct  symptoms  carefully  pieced  together,  in  the 
absence  of  some  symptoms  that  are  often  spoken  of 
as  characteristic.  Thus  there  may  be  no  pain  either 
in  the  hip  or  knee,  no  complaint  when  the  knee  or 
heel  is  jarred,  and,  to  a  casual  examination,  no  flexion 
and  no  lameness.  Close  investigation,  however,  shows 
that  there  is  slight  apparent  lengthening,  together 
with  slight  limitation  of  complete  flexion,  slight  mus- 
cular wasting,  and  slight  lameness.  In  another  case 
the  only  symptoms  ai-e  stiflhess  and  occasional  pain 


286  Manual  of  Surgery, 

(which  paients  regard  as  a  "  growing  pain  "  or  rheum- 
atism), and  limitation  of  flexion  and  rotation  of  the 
femur  in  the  acetabulum.  Thus  a  thorough  and  critical, 
but  always  gently  conducted  examination,  is  required. 
The  conditions  between  ^;vhich,  and  hip  disease,  mis- 
takes are  most  frequently  made,  are  disease  of  the 
spine  accom  panied  with  psoas  or  iliac  abscess,  disease 
of  the  sacro-  iliac  joint,*  abscess  under  the  glutei,  from 
whatever  cause,  infantile  paralysis,  congenital  disloca- 
tion o^  the  hip  joint,  and,  in  young  children,  lordosis, 
due  to  acute  rickets,  an  affection  which  imitates  hip 
disease  in  the  circumstance  that  the  limbs  are  often 
tender  on  movement. 

Complications. — In  a  very  large  proportion  of 
cases  in  which  the  disease  is  allowed  to  advance,  and  in 
some  even  in  which  treatment  has  been  at  once  brought 
to  bear,  suppuration  will  occur.  Matter  is  usually 
formed  within  the  joint,  and  passes  either  through 
the  cotyloid  notch,  or  through  the  bursa  under  the 
ilio-psoas,  to  reach  the  surface  in  Scarpa's  triangle,  or 
through  the  thin  posterior  part  of  the  capsule  to  appear 
under  the  glutei.  Some  abscesses,  however  (especially 
those  that  appear  late  in  the  disease),  are  outside  the 
joint,  and  are  due  to  suppuration  around  the  remains  of 
inflammatory  exudation.  Abscesses  may  present  at 
any  part  of  the  joint,  but  a  common  situation  is  under 
the  tensor  fasciae  femoris,  on  the  outer  part  of  the 
limb.  When  the  acetabulum  is  affected  matter  may 
form  within  the  pelvis  and  present  above  Poupart'g 
ligament.  Occasionally  pus  in  this  situation  forms  a 
communication  with  the  intestine,  so  that  faeces  escape 
into  the  abscess  cavity.  This  complication,  happily 
rare,  is  usually  fatal. 

Two  serious  complications,  amyloid  degeneration  of 
the  viscera,  and  tuberculous  meningitis,  must  here  be  re- 
ferred to.  Amyloid  degeneration,  indicated  by  albumin- 
uria and  enlargement  of  the  lia^er  and  spleen,  though 


Hip   Disease.  287 

nsually  met  with  only  when  discharge  has  been  copious 
and  prolonged,  is  sometimes  present  when  suppuration 
is  still  recent.  A  watch  should  therefore  be  kept  for  it 
in  all  cases  in  which  considerable  discharge  is  going 
on,  for  if  suppuration  can  be  arrested  when  the  amy- 
loid change  is  recent,  the  latter  may  entirely  disappear. 
At  a  subsequent  period,  however,  it  is  not  only 
incurable,  but  it  very  greatly  increases  the  risk 
attending  operative^  interference.  Tuberculosis  men- 
ingitis was  formerly,  when  hip  disease  was  so  often 
allowed  to  reach  an  advanced  stage,  much  more 
common  than  it  is  at  present.  But^  it  is  still  not 
very  rare,  and  may  occur  even  in  cases  in  which 
no  suppuration  has  taken  place,  and  at  any  period, 
even,  indeed,  after  the  joint  affection  has  long  been 
cured.  This  is  a  complication  that  always  passes  on 
to  a  fatal  termination.  Pulmonary  phthisis  is  de- 
cidedly rare  as'a  complication  of  hip  disease. 

Treatment. — This  consists,  in  the  early  period 
of  the  disease,  in  absolute  rest,  and  the  removal  of  any 
deformity  that  is  present.  These  ends  are  best  secured 
by  extension  by  means  of  the  weight  and  pulley.  The 
patient  is  placed  on  a  firm  mattress,  with  a  board 
beneath  it.  The  weight  is  applied  by  means  of  the 
well-known  stirrup  made  of  stout  strapping,  the  ends 
of  which  extend  half  way  up  the  thigh,  so  that  the 
ligaments  of  the  knee  are  not  subject  to  any  undue 
strain.*  The  weight,  which  takes  effect  rather  by  its 
constant  action  than  by  its  amount,  should  not  exceed 
three  or  four  pounds  in  children  under  ten,  and  five 
to  eight  in  patients  from  ten  to  twenty.  Heavier 
weights  than  these  are  seldom  required.  A  long 
splint  should  be  applied  to  the  opposite  or  sound  side, 
to  keep  the  patient  on  his  back  in  the  horizontal 
position.  As  to  the  affected  limb,  this  must  be  })laced 
in  the  position  to  which  the  disease  has  brought  it, 
*  This  is  not  shown  in  the  figures. 


288 


Manual  of  Surgery. 


Lordosis  due  to  flexion  must  be  removed  by  raising  the 
limb  till  the  spine  is  straight  (Fig.  ^^).  If  the  pelvis 
is  de])ressed  on  the  affected  side,  the  limb  must  be 
abducted  (Fig.  67)  till  the  two  iliac  spines  become 
horizontal ;  if,  on  the  contrary,  the  pelvis  is  drawn  up 
on  the  diseased  side,  the  liml)  must  be  adducted  till  the 
pelvis  is  again  square  (Fig.  G8).  When  these  directions 
have  been  carried  out,  when,  in  fact,  the  real  has  been 


Fig.  %<o. — Extension  in  Hip  Disease. 

substituted  for  the  apparent  position,  the  limb  must 
1)0  supported  in  this  attitude  (by  pillows,  or  some 
light  framework),  and  the  pulley  must  be  adjusted 
so  that  extension  is  made  in  the  long  axis  of  the 
thigh  (as  shown  in  the  various  figures).  When 
this  principle  is  carried  out,  the  weight  removes 
undue  interarticular  pressure,  whereas  if  extension 
does  not  correspond  with  the  long  axis  of  the  thigh, 
the  weight  acts  by  leverage,  and,  therefore,  tends  to 
increase,  instead  of  to  relieve,  the  })ressure  of  the  femur 
against  the  floor  of  the  acetabulum.  A  cradle  should 
keep  the  weight  of  the  bed  clothes  oft' the  foot.  As  flexion 
is  corrected  it  is  necessary  to  remove  some  of  the  pilh)ws 
and  to  shift  the  pulley,  so  that  the  weight  may  still  act 


Hip  Disease. 


289 


in  the  long  axis  of  the  thigh.  Though  the  weight  will 
remove  flexion  generally  in  from  a  fortnight  in  recent, 
to  two  months  in  old  cases,  it  has  little  or  no  influence 
either  on  abduction  or  adduction. 

As  to  alxluction  (showing  itself  as  apparent 
lengthening),  this  calls  for  no  S2:»ecial  treatment.  It 
w^ill  gradually  disappear  if  the  joint  remains  movable, 


Pi»?.  67. — Extensiou  of  the  Limb  in  a  flexed  and  abducted  Joint. 


while,  if  the  joint  becomes  tixed,  abduction  is  an  ad- 
vantage, Ijecause  the  apparent  lengthening  wdiich  it 
produces  will  tend  to  comj^ensate  for  any  real  shorten- 
ing that  may  have  resulted,  from  either  absorption  of 
the  articular  surfaces  or  arrested  growth  of  the  limb. 

xVdduction,  on  the  contrary,  as  it  leads  to  ap- 
parent shortening,  must,  if  possible,  be  removed. 
For  this  purpose  a  pound,  or  perhaps  two  pounds, 
is  added  to  the  amount  already  applied  to  the  affected 
limb.  A  long  splint  is  applied  to  the  sound  liml)  (if 
T— 21 


290 


Maa'c/al  of  Surgerv. 


tliis  lias  not  already  been  clone),  and  a  cord  fostened  to 
the  lower  end  of  this  splint  is  run  upwards  along  its 
outside  to  the  head  of  the  bed,  where  it  turns  over  a 
pulley  and  supjjorts  the  same  amount  of  \vei,i;ht  as 
that  appended  to  the  affected  limb.  Thus,  while  the 
diseased  limb  is  drawn  down,  the  sound  limb  is 
drawn  in  the  opposite   direction.      This   method  will 


Fig.  68.— Extension  of  the  Limb  in  a  flexed  and  adducted  Position. 


generally  remove  even  a  considerable  amount  of 
adduction,  i.e.  of  apparen!:  shortening,  in  the  course  of 
from  three  to  five  or  six  weeks. 

In  cases  of  long  standing  the  limb  may  be  so  fixed, 
although  there  is  no  anchylosis  (it  should  be  remem- 
bered that  bony  anchylosis  is  rare  in  liip  disease,  even 
when  repair  has  followed  long-continued  suppuration) 
that  the  weight  fails  to  secure  extension.  In  these  in- 
stances, when  the  child  is  under  chloroform,  the  limb 
may  be  straightened  through  two  or  three  degrees,  and 


Hip  Disease.  291 

then  the  weight  may  be  reapplied.  It  will  now  he 
found  that  the  limb  will  gradually  come  down  under 
the  influence  of  the  weight.  Very  slight  force  only 
should  be  used  in  this  proceeding,  and  anything 
approaching  the  old  method  of  forcibly  straightening 
the  limb  must  be  entirely  condemned. 

Mr.  Thomas  has  invented  a  splint  which  has 
deservedly  become  popular,  and  of  which  a  description 
may  be  found  in  any  recent  work  on  general  surgery. 
This  splint  is  very  useful  for  the  purpose  of  main- 
taining absolute  rest  in  acute  cases,  where  it  may 
with  great  advantage  be  combined  with  weight  ex- 
tension. By  its  help  the  child  can  be  lifted  without 
disturbance  of  the  joint.  It  is  also  very  useful  in  the 
convalescent  stage  to  prevent  a  return  of  flexion.  The 
chief  objection  to  this  splint  is  that,  if  long  continued 
it  is  apt  to  produce  muscular  atrophy,  especially  when 
the  bandage  used  to  fix  it  is  a])plied  tightly  around  the 
limb.  Another  drawback  is  that  it  does  not  exercise 
any  extension,  so  that  displacement  of  the  femur  up- 
wards and  shortening  of  the  limb  may  take  place  during 
its  use.  However,  when  necessary  weight  extension 
can  easily  be  combined  with  the  splint.  The  old 
leather  shield  splint,  and  the  various  forms  of  plaster 
of  Paris  cases  are  all  far  inferior,  in  every  respect,  to 
Thomas's  splint.  The  American  surgeons,  Tayloi",  Say  re, 
and  others,  have  invented  splints,  figured  in  all  the 
American  manuals.  Their  principle  is  to  maintain 
extension  and  mobility  of  the  joint  while  the  patient 
is  allowed  to  be  up  and  moving  about.  To  be  efficient, 
however,  they  require  very  frequent  leadjustment. 
They  have  never  become  popular  in  England. 

The  period  during  which  treatment  should  be  con- 
tinued varies  with  the  case.  It  must  always,  however, 
be  remembered  that  recovery  is  slow,  and  that  relapses 
are  very  prone  to  occur,  so  that  the  main  chance  of 
error  lies  in   rendtting  treatment  too  soon.      Weight 


292  Manual  of  Surgery. 

extension  sliould  be  continued  for  at  least  three 
months  after  pain  and  all  tendency  to  muscular  con- 
traction have  completely  disappeared,  and  if  the  case 
has  been  acute  a  full  six  months  should  be  allowed. 
The  weight  should  then  be  gradually  discontinued,  and, 
if  no  symptoms  are  observed,  a  Thomas's  splint  may  be 
applied,  and  the  chikl  be  allowed  to  be  up  on  crutches, 
wearing  a  high  boot  on  the  sound  side,  so  as  to  keep 
the  foot  of  the  diseased  limlj  off  the  ground. 

Treatment  of  abscesit*  in  liip  disease* — 
The  objections  formerly  valid  against  the  open- 
ing of  abscesses  in  hip  disease  have  been  set  aside 
by  the  methods  now  in  common  use  for  preventing 
septic  infection  of  the  wound  ;  and  abscesses  which 
used  to  be  left  to  form  large  collections,  now 
may,  and  should  be,  evacuated  as  soon  as  they  are 
detected.  When  the  patient  is  under  an  anaesthetic 
an  incision  about  an  inch  long  is  made  and  kept 
open  with  dressing  forceps,  while  matter  is  gently 
pressed  out  so  that  the  abscess  is  emptied  ;  a  piece  of 
drainage  tube,  just  long  enough  to  enter  the  abscess 
cavity,  is  inserted,  and  the  wound  is  dressed  with  "  pro- 
tective" and  antiseptic  gauze  in  the  usual  manner. 
Subsequently  the  dressings  are  changed  often  enough 
to  prevent  the  discharge  from  passing  beyond  the  gauze. 
By  this  method  abscesses  may  be  oj)ened  without  any 
rise  of  temperature,  or  local  disturbance.  When  this 
treatment  is  employed  in  cases  in  which  the  joint 
disease  has  become  inactive  no  further  suppuration 
will  occur,  and  the  wound  will  be  soundly  healed  in  a 
fortnight  to  three  weeks ;  while  in  those  in  which 
active  disease  is  still  in  progress  the  abscess  contracts, 
and  all  that  remains  is  a  sinus,  which  serves  to  afford 
exit  for  any  pus  that  is  produced  till,  as  repair  ad- 
vances, suppuration  comes  to  an  end.  By  following 
this  practice  of  opening  abscesses  early  the  extensive 
V>urru\ving   of   pus,   and   tiie  formation    of    numerous 


Excision  /x  Hip  Disease.  293 

fiinuses  about  the  joint,  formerly  so  common,  is 
pievented,  the  tissues  are  relieved  from  the  pre- 
judicial action  of  retained  pus,  fever  is  avoided,  and 
th,:  period  of  suppuration  is  largely  curtailed. 

fxeif^ioii  ill  lii|»  disi^ase.— With  the  majority 
of  suigeons  excision  of  the  hip  is  a  very  un- 
popular o^z^eration ;  for  when  it  is  performed  for 
advanced  disease,  and  when  the  health  has  be- 
come impaired,  tlio  wound  frequently  remains 
unhealed,  su})puration  remains  as  free  as  before 
the  operation,  and  the  patient  still  continues  to 
lose  health  and  strength.  In  short,  the  proceeding 
does  little  or  no  good,  either  locally  or  as  regards  the 
patient's  general  condition.  INIeeting  with  this  disap- 
pointing experience,  some  authorities,  liolding  the  view 
{see  page  265)  that  the  disease  is  attended  with  the 
local  deposit  of  tubercle,  and,  therefore,  little  likely  to 
undergo  rejiair  without  operative  interference,  and 
pointing  to  the  advantage  of  removing  the  affected 
structures,  and  so  of  averting  the  risk  of  systemic  in- 
fection, recommend  that  the  operation  should  be  per- 
formed at  an  early  period,  as  soon,  in  fact,  as  sup- 
puration is  detected.  In  the  early  stage,  however, 
it  is  now  well  known  that  ]>roperly  conducted  treat- 
ment by  rest,  and  the  evacuation  of  matter,  will  lead 
to  recovery  with  a  much  more  useful  limb  than  that 
which  is  ol^tained  by  excision.  There  are,  however, 
certain  conditions  for  which  it  is  advisable  to  perform 
excision,  although  tlie  result  of  the  operation  must 
often  be  very  doubtful.     These  are  : 

1.  When  the  whole  head  of  the  femur,  or  M'hat 
remains  of  it,  has  become  necrosed  and  detached,  so  as 
to  form  a  loose  sequestrum.  Tliis  proceeding,  how- 
ever, is  not,  strictly  speaking,  an  excision,  but  merely 
an  operation  for  dead  bone. 

2.  When,  in  spite  of  three  or  four  months  of  com- 
plete   rest    and    free    drainage,   suppuration    remains 


294  Manual  of  Surgery. 

copious,  and  the  general  liealtli  is  giving  "^^'^y,  pro- 
vided, however,  that  there  is  no  evidence  of  extensive 
disease,  either  of  the  femur  or  the  pelvis,  or  wide 
burrowing  of  matter  in  the  limb.  When  the  fenuir 
is  the  seat  of  chronic  osteo-myelitis,  whicli  sometimes 
involves  the  greater  part  of  the  shaft,  amputation 
is  the  only  adequate  operation  ;  and  when  the  pelvis 
is  largely  diseased,  excision  will  be  useful  only  in 
securing  free  drainage.  The  gouging  away  of  carious 
bone  from  the  pelvis  will  very  seldom  be  attended 
with  any  good  result. 

3.  When,  along  with  continued  suppuration,  there 
is  so  much  displacement  of  the  upper  end  of  the  femur 
that  the  limb  cannot  be  brought  into  good  position 
without  operation.  Here  excision  may  serve  the 
double  purpose  of  removing  distortion  and  of  arrest- 
ing suppuration.  In  any  of  the  above  conditions  the 
appearance  of  enlargement  of  the  liverj  or  of  albumen 
in  the  urine,  showing  that  amyloid  disease  of  the 
viscera  has  set  in,  may  be  an  additional  ground  for 
excision,  for  if  the  operation  can  arrest  suppuration, 
the  internal  organs  may  perfectly  recover.  When, 
however,  amyloid  disease  is  of  long  standing,  the 
operation  will  not  only  be  useless,  but  attended  with 
considerable  danger  to  life. 

Excision  is  now  performed  with  nuich  less  violence 
and  destruction  of  parts  than  was  formerly  the  case,  when 
the  custom  was  to  strip  the  whole  upper  end  of  the 
femur,  to  force  it  out  through  the  wound,  and  saw  across 
the  shaft  below  the  trochanters.  The  operation  vir- 
tually consists  merely  in  removingthe  head  of  the  femur, 
or  its  remains,  by  dividing  the  neck.  The  trochanter 
major,  in  all  but  exceptional  cases,  is  preserved,  and 
the  attachment  of  its  muscles  and  the  surrounding 
soft  parts  are  as  little  as  possible  interfered  with. 

Operation. — An  incision  down  to  the  back  of 
the    joint    is    made  about  four  inches  in  length,    and 


Amputation  in  Hip  Disease  295 

extending  from  tlie  base  of  the  trochanter  upwards 
in  the  course  of  the  fibres  of  the  glutei.  The  wound 
is  retracted,  and  the  capsule,  if  still  present,  is  opened. 
The  finger  is  then  passed  in  to  ascertain  the  con- 
dition of  the  bones  and  the  relation  of  the  neck  ;  a 
small  saw,  guided  by  the  finger,  is  next  introduced  ; 
the  neck  is  sawn  through  wheio  it  appears  to  l)e  sound, 
and  the  detached  portion  is  removed,  with  as  little 
injury  as  possible  to  the  surrounding  parts,  by  ex- 
tracting bone  forceps.  Should  it  be  clear  tliat  the 
trochanter  is  extensi\'ely  carious  it  must  be  removed, 
but  this  step,  it  must  be  noted,  largely  interferes  with 
the  future  usefulness  of  the  limb.  The  floor  of  the 
acetabulum  must  l)e  carefully  examined,  and  any 
sequestra  removed,  and  sliould  tliere  be  perforation  and 
abscess  in  the  pelvis,  free  drainage  should  be  provi<l('d 
by  removing  the  necessary  amount  of  bone  with  a 
gouge.  Bone  should  not,  however,  be  gouged  away 
merely  because  it  is  carious.  After  the  operation  the 
limb  may  be  placed  either  on  an  outside  splint,  inter- 
rupted opposite  the  wound ;  or  between  sand-bags 
with  a  weight  of  two  or  three  pounds  suspended  from 
the  foot  to  prevent  undue  retraction  and  shortening. 

The  conditions  adverse  to  the  success  of  the 
o[)eration  increase  so  rapidly  as  age  advances,  that 
excision  is  very  seldom  midertaken  in  patients 
above  the  age  of  twenty.  In  middle  life  it  is  justly 
regarded  as  inadmissible. 

Ampul  ntioii. — Surgical  opinion  has  recently 
moved  in  the  direction  of  reconnnending  a  more 
frequent  resort  to  amputation,  or  a  means  of  treating 
otherwise  ho}»eless  cases  of  hip  disease.  Experience 
has  shown  that  the  operation  is  less  fatal  than  was 
supposed.  It  is  nosv  clearly  seen  that  when  tlie 
disease  has  reached  a  certain  stage,  it  is  generally 
futile  to  anticipate  repair,  either  from  continued  rest 
or  from   excision.      It  has  often   been  observed  that 


2g6  Manual  of  Surgery. 

cliildren  show  very  great  rallying  power  when  a 
source  of  exhausting  suppuration  is  removed,  and  it  ia 
known  that  amyloid  degeneration,  unless  it  is  of  long 
standing,  is  no  bar  to  the  operation,  and  may  be  com- 
pletely recovered  from.  Obviously,  however,  amputation 
must  be  performed  only  when  the  patient's  recovery 
is  otherwise  hopeless.     The  operation  is  called  for  : 

1 .  When  hip  disease  is  complicated  with  extensive 
disease  of  the  femur  attended  with  copious  and 
persistent  sujjpuration,  and  especially  if  amyloid 
degeneration  is  present. 

2.  When  excision  has  been  performed  but  has 
failed  to  arrest  suppuration,  and  the  general  health 
is  giving  way.  Here  amputation  is  much  simplified 
by  the  previous  excision. 

3.  When  the  patient  is  steadily  losing  ground,  and 
it  is  believed  that  he  has  not  strength  sufficient  to 
secure  repair  after  excision. 

4.  In  some  cases  of  free  suppuration  connected 
with  advanced  disease  of  the  pelvis,  amputation  may 
be  advantageous,  either  by  securing  free  drainage  not 
otherwise  possiljle,  or  by  enabling  the  operator  to 
remove  diseased  bone  that  coultl  not  otherwise  be 
reached.  Generally,  however,  extensive  disease  of 
the  ])elvis  contra-indicates  am]nitation. 

As  the  patient  is  already  in  an  exhausted  condi. 
tion,  it  is  of  the  first  importance  that  little  blood 
should  be  lost,  and  that  the  operation  should  occupy 
as  short  a  time  as  is  compatible  with  its  careful 
execution.  Haemorrhage  must  be  guarded  against, 
either  by  the  use  of  Davy's  lever  or  of  an  efficient 
tourniquet.  The  method  by  transfixion  admits  of 
being  rapidly  carried  out,  but  the  resulting  stump  is 
too  short  to  allow  of  the  adaptation  of  an  artificial  limb. 
If,  however,  Furneaux  Jordan's  admirable  method  is 
used  a  long  muscular  stump  is  provided,  and  the 
patient  will,  on  recovery,  be  able  to  walk  well  on  an 


Disease  of  Kxf.e  Joixt.  297 

artificial  limb.  Hence  the  choice  of  the  methocl  in 
every  case  will  turn  on  the  condition  of  the  patient.  If 
he  is  in  a  state  to  bear  a  somewhat  prolonged  operation, 
Furneaux  Jordan's  plan  should  certainly  be  selected; 
but  if  he  is  so  exhausted  that  it  is  necessary  to  com- 
plete the  amputation  with  as  little  loss  of  time  as  pos- 
sible, the  transfixion  metliod  had  better  be  adopted. 

The  knee. — This  is  not  only  the  laigest  of  the 
joints,  but  it  is  singularly  liable  to  disease.  Some 
affections  met  with  here  are  very  rarely  seen  in  any 
other  joint ;  while  if  we  glance  at  the  various  diseases 
that  attack  the  joints,  it  is  the  knee  that  is,  in  almost 
every  instance,  most  prone  to  be  atlVcted.  The  knee 
is,  after  the  hip,  the  joint  in  which  deformity  is 
most  likely  to  occur,  and  the  most  dilhcult  to  remedy , 
and  in  which  pain  and  muscular  startings  are  most 
frequent,  severe,  and  hard  to  relieve  ;  in  which,  while 
suppuration  is  frequent,  it  is  the  most  fornudal»le  ;  iu 
wliich  we  are  most  often  driven,  in  neglected  cases,  to 
perform  excision  or  amputation.  While,  on  the  other 
hand,  there  is  no  joiut  in  which  appropriate  treatiuent  is 
attended  with  more  satisfactory  results.  It  is  therefore 
an  articulation  which  demands  special  consideration. 
The  features  of  strv.moihs  disease  sxevceW  illustrated  in 
this  joint.  The  afiection  begins  either  as  a  low  form 
of  synovitis,  often  at  first  circumscribed,  but  subse- 
quently extending  to  the  whole  membi-ane ;  or  as 
inflammation  of  the  cancellous  ti.ssue  (in  young 
subjects  epiphysitis)  of  the  lower  end  of  the  femur 
or  upper  end  of  the  tibia.  When  disease  be- 
gins as  synovitis,  the  knee  is  bent  at  an  angle 
of  about  140",  and  though  it  can  be  flexed,  it 
cannot  be  fully  extended.  If  the  process  is  acute  the 
joint  may  be  distended  with  fluid,  so  that  fluctuation 
is  distinct.  Usually,  however,  swelling  is  inconsider 
able,  or  so  slight  that  it  can  be  detected  only  by  care- 
ful measurement,  and  is  due  mainly  to  thickening  of 


298  Manual  of  Surgery. 

the  synovial  membrane,   chiefly  apparent  by  the  side 
of  the  ligamentum  patelhe. 

In  later  stages  tlie  membrane  undergoes  pulpy  de- 
generation (page  249) followed  by  suppuration.  The  li^ira- 
ments  become  softened,  and  gradually  elongated,  while, 
owing  to  reflex  contraction  of  the  ha,mstring  muscles, 
a  remarkable  distortion  is  produced.  This  is  threefold; 
the  bones  of  the  leg  becoming  flexed,  displaced  back- 
wards and  outwards,  and  rotated  outwards  so  that  the 
foot  is  everted.  Flexion  is  due  to  the  action  of  the 
hamstrings,  while  the  dis})lacement  outwards  combined 
with  eversion  is  due  to  the  fact  that  the  powerful  biceps 
muscle  is  inserted  into  the  outer  and  front  part  of  the 
head  of  the  fibula,  and,  as  a  strong  fascia  covering 
the  tibialis  anticus,  into  the  crest  of  the  tibia,  so  tliat 
it  is  a  strong  external  rotator.  Lameness,  due  to  the 
position  of  the  limb,  or  to  tenderness  of  the  joint, 
is  present.  Pain,  and  abnormal  heat  of  the  surface, 
though  often  present,  are  so  frequently  absent,  or  so 
slightly  marked,  tliat  they  arci  much  less  reliaV)Ie 
symptoms  than  flexion  and  pufly  (MdargcMuent  of  the 
joint. 

When  disease  begins  in  the  articular  end  either 
of  the  femur  or  the  tibia,  the  symptoms,  at  fir.st 
very  slightly  marked,  are  local  pain,  tenderness  on 
firm  pressure,  ])ufly  swelling  of  the  soft  pai'ts,  lame- 
ness, and  inability  of  the  patient  to  completely  extend 
the  limb.  It  is  in  this  form  of  disease  that  startings 
of  the  limb,  due  to  reflex  muscular  contraction,  make 
their  appearance  early,  and  often  gi\adually  increase  in 
severity.  As  the  disease  ad%'ances  the  joint  itself  be- 
comes involved,  sometimes  l)y  diiect  extension  of 
inflammation  leading  to  chronic  synovitis;  but  fre- 
quently by  the  entrance  of  ])us  into  the  cavity  of  the 
joint  through  a  perforation  of  the  articular  cartilage  ; 
when  this  opening  is  small  and  indirect,  the  symptoms 
are  at  first  not  very  marked,  but  when  matter  in  any 


Disease  of  Knee  Joint.  299 

considerable  quantity  bursts  directly  into  the  joint, 
violent  and  destructive  inflammation  is  at  once  pro- 
duced, attended  with  rapid  distension  of  the  synovial 
cavity  with  pus,  severe  pain,  high  temperature,  and 
constitutional  disturbance. 

Treatment. — At  the  earliest  moment  at  Avhich 
disease  can  be  detected  the  patient  must  be  for- 
bidden to  put  his  foot  to  the  ground,  and  the  joint 
must  be  placed  at  absolute  rest  in  splints,  of  which 
the  best  form,  made  of  carefully  mouhled  leather,  is 
shown  in  Fig.  51.  These  should  extend  from  the 
upper  tliird  of  the  thigh,  nearly  to  the  ankle,  so  that 
the  whole  limb  is  fixed.  They  must  be  worn  con- 
stantly, day  and  night,  and  be  removed  only  twice  or 
three  times  a  week  for  attention  to  the  skin,  and  must 
be  immediately  reapplied.  Thus  treated,  in  the  great 
majority  of  cases  incipient  disease  will  steadily  recede, 
and  in  the  course  of  from  three  to  six  or  nine  months 
complete  recovery  with  unimpaired  movement  will  take 
]  )lace.  A  modification  of  this  plan,  when  swelling  and 
lieat  have  subsided,  is  to  employ  Thomas's  knee  splint, 
so  that  the  patient  is  allowed  exercise  without  throw- 
ing weight  on  the  affected  joint.  If,  however,  under 
this  method,  any  return  of  symptoms  is  observed,  the 
leather  splints  and  the  horizontal  position  ought  to 
be  at  once  resumed.  In  cases  in  which  the  joint 
has  become  flexed,  no  forcible  attempt,  either  by 
manipulation  or  instruments,  should  be  made  to 
straighten  it,  but  the  splints  should  be  moulded  to  its 
present  position.  With  rest,  and  the  subsidence  of 
muscular  spasm,  it  will,  in  the  course  of  a  few 
weeks,  often  within  a  month,  spontaneously  subside 
into  a  posture  of  extension.  In  cases  of  any  standing 
this  process  is  very  gradual,  and  it  is  necessary 
to  follow  it  up  by  adapting  splints  whose  shape  must 
be  altered  to  keep  pace  with  the  improved  position  of 
the  bmb.     The   improveuujnt  produced  by   rest  may 


300  Manual  of  Surgerv. 

be  advanced  by  a  succession  of  small  blisters,  or  the 
application  of  oleate  of  mercury,  or  of  gentle  pressure 
by  means  of  Martin's  elastic  bandage.  Friction  and 
douching  with  salt  water,  etc.,  means  which  parents  are 
often  so  anxious  to  employ,  are  usually  harmful,  as  they 
involve  disturbance  of  the  joint.  Night  screams  arc 
best  relieved  by  the  use  of  the  actual  cautery,  lightly 
applied,  and  repeated,  if  necessary,  in  three  or  four 
days  ;  and  by  combining,  wdth  the  splints,  the  iise  of 
the  weight  and  pulley.  In  this  case  the  limb  must 
be  raised  and  supported  in  such  a  position  that  the 
tibia  is  horizontal,  and  that  extension  acts  in  the 
long  axis  of  the  leg.  When  disease  involves  the  ends 
of  the  bones,  the  treatment  just  described  must  be 
carried  out.  In  these  instances,  however,  it  is  of  the 
highest  importance  to  prevent  the  extension  of  mis- 
chief to  the  joint  itself.  Rest  must  be  scrupulously 
maintained.  Sliould  matter  be  detected,  it  must  be 
at  once  evacuated ;  and  even  though  no  fluctuation 
can  be  felt,  if  local  pain,  tenderness  on  pressure,  and 
pufty  swelling  and  redness  of  the  surface  are  present, 
the  existence  of  pus  must  be  suspected,  and  an  in- 
cision through  the  periosteum  should  be  made,  and  the 
bone  should  be  explored  by  puncture  with  a  fine  drill, 
and  if  any  matter  is  found,  a  fi-ee  opening  should  be 
made,  so  that  the  chance  of  the  escape  of  matter  into 
the  joint  may  be  provided  against. 

Acute  arthritis  of  infants  (page  239)  is  common  in 
the  knee.  The  joint  becomes  painful,  restricted  in  its 
movements,  and  tender  to  the  touch  ;  and  pus,  raj^idly 
formed  in  large  quantity,  distends  the  joint,  and  soon 
becomes  extravasated  into  the  surrounding  tissues.  If 
incisions  are  made,  and  free  drainage  is  provided,  as 
soon  as  matter  forms,  and  a  posterior  splint  is  applied, 
complete  recovery,  with  free  movement,  may  often  be 
secured.  But  in  neglected  cases  the  ligaments  and 
ends  of  the  bones  are  rapidly  destroyed ;  and,  if  the 


Osteo-Arthritis.  301 

patient  recovers,  the  joint  remains  more  or  less  loose, 
iiail-like,  and  distorted,  and  the  limb  is  arrested  in  its 
growth  and  useless. 

In  any  form  of  hlood  poisoninr/  (page  226)  attacking 
the  knee,  the  joint  must,  if  the  patient's  condition 
allows,  be  at  once  placed  at  rest  on  a  splint,  in  tlie 
best  available  position,  and  covered  with  warm  lead 
and  opium  lotion  ;  or,  if  pain  is  severe,  with  a  liniment 
of  opium  and  belladonna.  If  the  joint  becomes  dis- 
tended it  should  be  emptied  with  a  tine  aspirator 
needle.  If  the  tin  id  is  purulent,  and  soon  reforms, 
antiseptic  incision  and  drainage  will  be  called  for.  In 
many  cases  in  which  the  patient's  general  condition 
is  grave,  and  in  which  other  lesions  are  present,  if 
the  joint  is  in  a  quiescent  state  and  not  much  dis- 
tended, it  is  best  to  postpone  active  interference,  and 
merely  to  secure  rest. 

Osteo-arthritis,  of  frequent  occurrence  in  persons 
over  fifty,  and  sometimes  found  in  much  younger  sub- 
jects, comes  on  with  stitliiess  and  pain  (especially 
marked  after  rest),  weakness,  and  creaking,  gi-ating,  or 
crackinof  on  movement.  Swelliiifr  due  to  effusion,  thoufih 
it  may  be  considerable,  and  even  amount  to  hydrops 
articuli,  is  usually  only  slight.  "  Lipping,"  due  to  the 
heaping  up  of  new  bone  along  the  articular  margins,  can 
often  be  felt ;  and  in  advanced  cases  the  patella  and  the 
articular  ends  of  the  bones  become  enlarged  and  altered 
in  shape ;  while  in  some  instances  masses  of  cartilage, 
developed  in  the  synovial  fringes,  and  subsequently 
becoming  detached,  form  "  loose  bodies  "  in  the  cavity 
of  the  joint ;  pain  is  often  severe,  and  the  patient 
becomes  crippled  by  lameness.  The  disease  generally 
attacks  other  joints,  especially  the  opposite  knee.  For 
treatment  see  page  278. 

Syphilitic  disease  (page  224),  in  the  form  either  of 
synovitis  with  effusion,  or  of  gummatous  infiltration  and 
thickening  of  the  subsynovial  tissue,  often  combined 


302  Manual  of  Surgery. 

with  periostitis  of  the  ends  of  one  of  the  bones,  is  met 
with  more  often  in  this  than  in  any  other  articiihition. 
Displacement  of  the  semilunar  cartilages  (internal 
derangement,  or  subluxation  of  the  knee  joint)  is  de- 
scribed at  page  25G,  and  the  subject  of  "loose  bodies '' 
is  treated  of  at  page  250. 

Ankle. — Strumous  disease  of  this  joint  usually 
takes  the  form  of  an  insidious  chronic  synovitis, 
though  it  may  arise  from  extension  of  inflammation 
from  the  lower  epiphysis  of  the  tibia,  or  from  one  of 
the  tarsal  bones.  The  symptoms  are  lameness,  en- 
largement of  the  joint,  wasting  of  the  muscles  of  the 
calf,  and,  though  these  are  often  absent,  pain  and  heat 
of  the  surfixce,  and  restricted  movement.  Swelling, 
which  is  frequently  in  children  the  most  reliable  feature, 
occurs  as  puffy  enlargement  by  the  sides  of  the  tendo 
Achillis,  so  that  the  joint  has  an  appearance  of 
increased  width  when  viewed  from  behind  ;  but  it  can 
also  be  seen  around  the  malleoli,  and  in  front,  beneath 
the  extensor  tendons.  It  is  often  difficult  alike  in 
early  and  advanced  cases,  and  even  when  sujjpuration 
has  occurred  and  has  led  to  the  formation  of  sinuses, 
to  decide  whether  disease  is  situated  in  the  ankle  joint 
or  is  confined  to  the  astragalus  or  the  os  calcis.  In 
early  cases  this  is  not  very  material,  as  treatment  by 
complete  rest  is  essential  in  both  instances ;  but  in 
advanced  disease  the  difierential  diagnosis  is  highly 
important.  I  have  more  than  once  known  Syme's 
amputation  performed  for  what  was  believed  to  be 
destructive  disease  of  the  ankle  joint,  but  which 
proved  to  be  caries  of  the  tarsus  that  might  have 
been  dealt  with  without  amputation,  while  the  joint 
itself  was  perfectly  healthy.  The  foot  should  never  be 
removed  until  the  surgeon  has  convinced  himself  that 
a  probe  passed  into  any  sinuses  that  exist  really  enters 
the  joint.  In  strumous  disease  of  the  ankle  the  joint 
Qiust   be  at  once  enclosed  in   lateral    leather  splints 


Disease  of  Ankle  Joint.  303 

(Fig.  54;  page  248),  and  the  patient  must  bear  no 
weight  upon  the  limb.  Any  matter  that  forms  must  be 
at  once  antisepticallj  evacuated.  There  are  very  few 
cases  indeed  in  which  this  treatment,  combined  with  cod- 
liver  oil,  iron,  and  good  air,  will  not  lead  to  recovery, 
usually  with  restoration  of  the  movements  of  the  joint, 
Osteo-artJirifyiti  j>resents  no  features  calling  for  detailed 
description.  The  disease  is  usually  not  confined  to 
the  joint,  but  involves,  at  the  same  time,  the  adjacent 
tarsal  articulations,  and  is  often  associated  with  a  very 
troublesome  form  of  flat  foot,  resulting  from  relaxation 
of  the  plantar  ligaments,  a  condition  which,  along  with 
stiftness  of  the  ankle  joint  itself,  greatly  cripples  the 
patient.  The  local  treatment  consists  in  protection 
against  cold  and  damp,  and  the  use  of  the  hot  douche 
or  steam  bath,  moderate  exercise,  and  some  support 
for  the  plantar  aich.  When,  however,  the  joint 
is  swollen  and  tender  no  mechanical  support  can  be 
borne,  and  the  patient  should  be  provided  with  boots 
of  very  soft  leather  or  cloth,  with  low  heels  and 
wide  soles,  while  warmth  and  hot  douching  are  per- 
severed with,  and  the  rules  stated  on  page  278  are  care- 
fully followed.  The  ankle  and  the  neighbouring  tarsaj 
joints,  together  with  the  fibrous  structures  of  the  sole, 
including  all  the  ligaments,  are  not  larely  the  seat  of 
urethral  urethritis  (page  229)  of  an  acute  and  severe 
type.  In  cases  of  rapidly  increasing  Hat  foot  in  young 
adidts,  the  presence  of  gonorrhoea  must  not  be  over- 
looked. The  affection  often  assumes  a  severe  form, 
and  the  arch  is  completely  lost.  It  is  necessary  to 
kee})  the  patient  for  a  time  completely  off  his  feet 
while  the  treatment  indicated  on  page  231  is  being 
followed.  And  for  some  months  the  patient  should 
rest  his  feet  as  much  as  possible,  and  should  wear 
either  the  surgical  sole,  or  some  equivalent  support. 


3^4 


V.     INJURIES  AND  DISEASES  OF  MUSCLES, 
TENDONS,  FASCIA,  AND  BURS^. 

AViLLiAM  J.  Walsh  AM. 

Muscles. 

^Vouiids  of  muscles,  like  those  of  other  soft 
tissues,  may  be  incised,  lacerated,  punctured,  or  con- 
tused, and  call  for  but  few  remarks.  When  a  muscle 
is  divided  transversely  to  its  fibres,  the  cut  ends  con- 
tract, causing  the  wound  to  gape.  They  should,  there- 
fore, be  approximated  as  much  as  possible,  by  placing 
the  part  in  such  a  position  as  to  relax  the  muscle,  and 
sutured  with  animal  ligature,  as  catgut  or  kangaroo 
tail  tendon,  the  wound  closed,  and  the  parts  placed  at 
absolute  rest.  When  the  wound  is  deep,  or  longi- 
tudinal to  the  fibres,  a  drainage  tube  had  better  be  in- 
serted, as  the  discharge  is  likely  to  be  pent  up  by  the 
bulging  of  the  fiesliy  belly  of  the  nmscle.  Should 
the  muscle  have  lost  its  contractility,  and  appear  so 
lacerated  or  contused  that  it  must  obviously  die,  the 
injured  portion  may  be  cut  away.  Wounded  muscle 
generally  unites  by  fibrous  tissue,  but  the  formation 
of  new  muscle  fibres  has  in  a  few  rare  instances  been 
observed. 

Riiptiire.— Subcutaneous  ruptuie  of  a  muscle 
may  be  caused  by  a  sudden  or  violent  involuntary 
action,  as  in  trying  to  save  a  fall,  or  during  vomiting, 
or  an  attack  of  tetanus  or  delirium.  The  muscles,  per- 
haps, most  frequently  ruptured  in  this  way  are  the 
pectoralis  major,  deltoid,  rectus  fenioris  and  abdomi- 
nis, gastrocnemius,  adductors  of  tlie  tliigh,  and  ox- 
tensor  brevis  of  the  foot.  The  rui)ture  may  be  c(jm- 
plete  or  partial,  and  may  occur  through  the  mriscuiar 


Jnjuries  of  AlrscLEs.  305 

tissue  itself,  or  at  the  insertion  of  the  muscle  into 
either  its  tendon  or  the  bone.  Union  generally  takes 
place  by  fibrous  tissue,  but  sometimes  suppuration 
occurs,  and  an  abscess  results. 

Symptoms. — The  rupture  is  attended  by  local 
pain,  perhaps  by  a  sensation  of  tearing  or  snapping. 
When  a  few  tibres  only  are  torn,  the  inj  ury  may  escape 
notice,  though  it  may  be  followed  for  many  months  by 
pain  and  stiffness,  which  may  be  attributed  to  rheuma- 
tism. In  complete  rupture  the  function  of  the  paii  is 
lost.  The  ruptured  ends  retract,  causing  a  hard 
swelling  above  and  below  the  rent,  which  can  often 
be  felt  as  a  gap  ;  or  blood  may  be  extravasated  be- 
tween the  ruptured  ends,  giving  rise  to  a  fluctuating 
swelling,  and  subserpiently,  as  it  makes  its  way  to- 
wards the  surface,  to  ecchymosis  and  discoloration  of 
the  skin. 

Treatment. —  The  ends  of  the  rujttured  muscle 
should  be  approximated  by  carefully  applied  bandages 
or  s})lints,  whilst  evaporating  lotions  or  an  ice  bag 
should  be  used  to  control  blood  extravasation  and 
prevent  inflammation.  Should  a  blood  tumour  form,  it 
should  not  be  opened,  as  the  blood  will  in  time  be  pro- 
bably absorbed.  Jf,  however,  suppuration  occurs,  an 
early  exit  should  be  given  to  the  pus. 

Iiillauiiiiatioii  aud  abscei^is. —  Inflammation 
of  muscle,  or  myositis,  may  follow  an  injury  such  as  a 
strain  or  rupture  of  a  few  fibres ;  or  it  may  spread  to 
the  muscle  from  the  tissues  around.  It  may  also  occur 
idiopathically,  and  is  then  generally  spoken  of  as  rheu- 
matic ;  and  it  is  of  frequent  occurrence  in  septicaemia 
and  pyaemia,  when  it  usually  quickly  ends  in  suppura- 
tion. 

The  chief  symptoms  are  pain  increased  on  move- 
ment, swelling,  and,  when  the  aflected  muscle  is  super- 
ficial, heat  and  redness.  Except  when  the  result  of 
pyicmia,  it  usually  teriuinates  in  resolution.  Should 
U— 21 


3o6  Manual  of  Surgery. 

an  abscess  form,  rigors  followed  by  fluctuation,  and 
later  j^ointing,  or  signs  of  deep  suppuration,  will  bo 
present. 

The  treatment  indicated  is  rest,  soothing  applica- 
tions, belladonna  or  opiate  liniments,  and,  where  pus 
has  formed,  an  early  incision. 

Hypertrophy,  or  simple  increase  in  size,  may 
occur  both  in  the  voluntar}'-  and  involuntary  muscles. 
Familiar  examples  of  the  former  are  seen  in  the 
muscles  of  the  limbs  of  athletes  ;  of  the  latter,  in  the 
bladder  and  intestines,  as  the  result  of  obstruction  to 
the  passage  of  urine  and  faeces. 

Ati-opliy  and  degeiiei'sitioii.— The  chief  de- 
generative changes  in  muscle  are  :  (1)  simple  atrophy  ; 
and  (2)  granular,  (3)  fatty,  and  (4)  waxy  or  vitreous 
degeneration.  In  simple  atrophy  the  muscular  fibres 
merely  waste  and  get  smaller,  but  do  not  lose  their 
striation,  and  are  capal3le  of  being  completely  re- 
stored ;  whilst  in  the  other  forms  the  fibres  undergo 
distinct  pathological  changes,  and  their  function  is  en- 
tirely and  permanently  lost.  Simple  atrophy  may 
occur  from  a  variety  of  causes.  In  surgical  practice 
it  is,  perhaps,  most  frequently  met  with  as  a  conse- 
quence of  the  disuse  of  a  part,  as  for  example  trom 
chronic  joint  disease.  The  granular,  fatty,  and  waxy 
degenerations  occur  as  the  result  of  acute  febrile 
disease,  lead  poisoning,  scrivener's  palsy,  disease  of  the 
nerve  centres,  etc.  Though  sometimes  occurring  alone, 
they  are  often  intermixed.  They  may  all  be  present, 
as  well  as  simple  atrophy,  in  the  following  diseases, 
of  which  a  short  account  is  given. 

Progressive  muscular  atrophy  is  a  disease  of 
adult  life,  and  consists,  as  the  name  implies,  of  a  slow 
and  nearly  always  progressive  atrophy  of  the  voluntary 
muscles,  and  consequent  increasing  weakness  and 
paralysis. 

The  cause  of  the  disease  is  often  obscure.      It  has 


Progressive  Muscular  Atrophy.        307 

been  attributed  to  excessive  exercise,  exposure  to  cold 
and  wet,  to  syphilis,  fevers,  lead  poisoning,  and  injury 
of  the  spine.  It  is  often  hereditary,  and  is  more  com- 
mon in  the  male  sex,  and  in  the  middle  period  of  life. 

Pathology. — Although  it  is  still  thought  by  some 
to  be  essentially  a  primary  disease  of  the  muscles, 
it  is  now  generally  held  that  the  wasting  of  the 
muscles  is  secondary  to  disease  of  the  multipolar  nerve 
cells  in  the  anterior  cornua  of  the  spinal  cord.  These 
cells,  amongst  other  pathological  changes  in  the  grey 
and  wliite  substance  of  the  cord,  have  been  found 
atrophied  and  degenerated  ;  but  whether  such  changes 
should  be  regarded  as  inflammatory  or  degenerative  is 
still  undetermined.  The  muscles  ajDpear  paler  than 
natural,  and  in  various  stages  of  atrophy.  They  are 
said  by  Charcot  to  undergo  simple  atrophy  only  ;  but 
other  observers  have  noticed,  in  addition,  granular, 
fatty,  and  vitreous  degenerations. 

Sym'ptoms. — The  short  muscles  of  the  thumb  and 
little  finger,  especially  those  of  the  right  side,  are 
generally  first  afiected ;  then  the  interossei,  giving  to  the 
hand  a  characteristic  claw-like  appearance  (the  main  en 
griff e).  Thence  the  atrophy  spreads  up  the  arm  to  the 
muscles  of  the  trunk,  or  missing  those  of  the  fore-arm 
falls  upon  the  deltoid,  or  attacks  the  muscles  of  the 
opposite  hand.  In  rare  instances  the  atrophy  starts 
in  some  of  the  muscles  of  the  trunk,  and  very  excep- 
tionally in  those  of  the  lower  extremity,  but  it  is  ex- 
ceedingly uncommon  for  it  to  spread  to  them.  Previous 
to  the  atropliy,  pain  and  cramps  or  fibrillar  tremors  in 
the  muscles  are  commonly  noticed.  In  the  later  stages 
the  limbs  become  variously  deformed  from  unequal 
wasting  of  the  muscles,  and  the  unbalanced  action 
of  their  antagonists.  The  muscles  respond  both  to  the 
faradic  and  continuous  current,  but  more  and  more 
feebly  as  the  disease  advances,  till  in  tlie  later  stages 
they  cease  to  do  so  altogether.    The  reflexes,  which  may 


3o8  Manual  of  Surgery. 

at  first  be  increased,  steadily  diminish,  1  ut  are  nevei 
quite  lost  till  the  muscle  is  entirely  destroyed.  The 
sensibility  of  the  skin  is  never  affected,  neither  does  it 
undergo  atrophic  changes  ;  the  bladder,  the  rectum,  and 
the  sexual  functions  are  not  interfered  with.  The 
patient  usually  dies  from  some  bronchial  trouble,  con- 
sequent upon  the  weakness  of  the  respiratory  muscles. 

Treatment. — Tliere  is  no  known  remedy  for  the 
disease,  but  phosphorus,  arsenic,  and  cod-liver  oil  may  be 
given  internally,  whilst  blisters  to  the  spine,  galvanism, 
and  the  hot  baths  of  Aix-la-Chapelle  should  be  tried. 

Pseiido-hypei'tropliic  paralysis  is  a  disease  of 
early  life,  and  consists  essentially  in  a  great  increase 
of  the  interfibrillar  connective  tissue  and  fat,  attended 
with  simple  atrophy  of  the  muscle  fibres.  It  is  charac- 
terised by  muscular  wasting  and  increasing  para- 
lysis, and  in  typical  cases  by  apparent  hypertrophy  of 
the  muscles  of  the  calves  and  gluteal  regions. 

The  cause  of  the  disease  is  obscure.  In  many  cases 
it  is  undoubtedly  hereditary,  and  occurs  in  several  mem- 
bers of  the  same  family.  It  is  much  more  common  in 
boys  than  in  girls,  and  when  inherited  descends  through 
the  female  line. 

Pathology. — Whether  the  disease  should  be  regarded 
as  one  essentially  of  the  muscles,  or  the  condition  of 
the  muscles  as  secondary  to  a  lesion  of  the  spinal  cord, 
is  still  a  disputed  point,  as  opportunities  for  examining 
the  cord  have  been  few.  The  muscles  in  the  early 
stages  shew  a  great  increase  of  the  interstitial  connec- 
tive tissue  and  infiltration  with  fat,  whilst  in  the  later 
stages  the  fibres  are  found  to  have  undergone  atrophy, 
and  to  be  more  or  less  completely  replaced  by  fat. 
The  muscles  hrst  affected  are  usually  those  of  the  lower 
extremity,  especially  of  the  calf  and  buttock.  Later 
all  the  voluntary  muscles  may  be  implicated,  though 
the  hypertrophic  changes  in  these  are  seldom  so  marked. 

Symptoms. — The    onset   of    the    disease    is   very 


PsEUDO-HyFERTROPHIC    PaRALYSIS.  309 

gradual.  The  child  is  unsteady  on  its  feet,  stumbles 
in  walking,  and  readily  falls.  Later,  as  the  extensor 
muscles  of  the  knees  and  extensors  and  flexors  of  the 
hips  become  more  affected,  equilibrium  in  the  upright 
position  is  maintained  with  diflicalty.  He  stands 
with  his  feet  far  apart,  so  as  to  widen  his  base  of 
support,  his  heels  frequently  drawn  up  from  the  ground 
by  the  contraction  of  the  muscles  of  the  calves,  and  his 
shoulders  carried  backwards,  and  the  lower  part  of  the 
spine  in  consequence  thrown  into  a  state  of  lordosis. 
The  lordosis  disappears  on  sitting,  and  apparently 
depends  on  the  tilting  forAvards  of  the  pelvis,  due  to  the 
weakness  of  the  hamstring  muscles.  In  walking,  the 
body  is  swayed  from  side  to  side  in  order  to  bring  the 
centre  of  gravity  at  each  step  well  ov  er  the  leg  that  is 
on  the  ground,  llising  from  the  recumbent  position  is 
difficult.  He  lirst  turns  on  his  face,  then  gets  on  his 
hands  and  knees_,  and  then,  extending  his  knees,  places 
his  hands  on  them,  and  then  higher  and  higher  up  the 
thighs,  pushing  his  body  up  by  these  means  ;  *'  climbing 
the  thighs/'  as  it  has  been  called.  If  the  child  is  seen 
during  the  hypertrophic  stage,  the  muscles  of  the  calf, 
and  probably  those  of  the  buttock  and  loin,  are  found 
enlarged.  The  enlarged  muscles  feel  lirm  and  hard, 
but  on  testing  them  with  the  faradic  current  their 
motor  power  is  found  diminished  ;  and  if  a  small 
piece  of  muscle  is  removed  by  Leech's  trocar  it  will 
show  the  characteristic  pathological  changes.  In  rare 
instances  the  pseudohypertrophic  change  has  been  ob- 
served in  all  the  muscles  ;  but,  as  a  rule,  it  is  limited 
to  those  mentioned,  the  other  muscles,  especially  the 
lower  portion  of  the  pectoralis  major  and  latisBimus 
dorsi,  appearing  wasted.  The  patellar  reflex  is  at  first 
diminished,  and  is  later  absent.  The  intellect  is  often 
weak,  but  at  other  times  unaffected.  The  disease  is 
very  chronic  in  its  course,  and  is  attended  in  its  later 
stages    by   contraction  and  distortion.     The   patients 


31  o  Manual  of  Surgery. 

usually  die  of  exhaustion  or  from  the  rcbpiratory 
muscles  becoming  affected. 

Treatment — Shampooing  and  faradisation  in  the 
earlier  stages  may  be  useful  ;  in  the  later  stages 
nothing  has  been  of  any  avail. 

Ossifiratioii  of  muscle  may  occur  as  the  re- 
sult of  chronic  irritation  or  inflammation.  The  osseous 
material,  which  has  the  structure  of  normal  bone,  is 
deposited  in  the  proliferating  connective  tissue  between 
the  muscle  fibres,  causing  the  latter  to  atrophy.  Ex- 
amples of  ossification  are  occasionally  met  with  in  the 
adductor  muscles  in  persons  who  ride  a  great  deal 
(rider's  bone),  and  it  was  formerly  not  uncommon 
in  the  deltoid  muscle  of  soldiers,  as  the  result  of 
shouldering  arms  (the  drill  bone).  I  have  seen  it  in 
the  rectus  in  cases  of  Cliarcot's  disease  of  the  hip  ; 
and  Abernethy  relates  the  case  of  a  boy  in  whom  bone 
was  constantly  developed  in  the  muscles  after  a  blow 
or  other  injury.  Specimens  of  ossification  of  the 
muscles  of  the  back,  and  of  the  vastus  internus,  are  to 
be  found  in  various  museums.  Blisters,  with  the  in- 
ternal use  of  mercury  or  iodide  of  potassium,  appear  to 
have  given  i-elief  in  some  instances. 

Tiinioiii'S. — Primary  tumours  in  muscle  are  rare ; 
but  fatty,  fibrous,  myxomatous,  and  more  rarely  enchon- 
dromatous  and  sarcomatous  growths  have  all  been  met 
with.  Blood  and  hydatid  cysts  are  of  more  frequent 
occurrence,  and  syphilitic  gummata  are  ])articularly 
common.  Secondary  growths  are  more  often  met  with, 
the  muscles,  in  common  with  the  other  tissues,  being 
not  infrequently  affected  in  the  general  dissemination 
of  carcinomatous  and  sarcomatous  growths.  Muscle 
may,  of  course,  also  be  involved  in  the  extension  of 
epitheliomata  from  the  skin  or  mucous  membrane,  and 
in  sarcomata  growing  from  the  periosteum  or  bone. 


Injuries  of  Ten  pons,  311 

Tendons. 

^VoiiikIs. — The  tendons  perhaps  most  frequently 
wounded  are  tliosc.  of  the  flexorn  aud  extensors  of  the 
fingers.  They  nlxiuld  be  carefully  united  by  animal 
sutures,  kangaroo  tail  tendon  being  one  of  the  best, 
and  the  parts  placed  at  rest  in  such  a  position  as  to 
approximate  the  divided  ends.  When  the  injury  has 
been  overlooked,  or  union  fails,  the  divided  ends, 
which  are  often  widely  separated  by  muscular  con- 
traction, become  adherent  to  the  sheath  and  surround- 
ing tissues,  and  the  function  of  the  muscle  is  impaired 
or  lost.  AVhen  the  patient  is  young,  and  the  local 
and  general  conditions  are  favourable  for  operation, 
an  incision  should  be  made  over  the  cicatrix  of  the 
former  wound,  the  ends  of  the  divided  tendon  searched 
for,  freed  from  adhesions,  refreshed  by  shaving  off  the 
last  half  inch  of  each  obliquely  in  opposite  directions 
so  as  to  bring  them  together  splice-wise,  and  sutured 
as  in  a  recent  wound.  These  operations,  tliough 
often  disa[ipointing,  are  sometimes  attended  with  very 
brilliant  results,  as  in  a  case  recently  under  the  care 
of  my  colleague,  Mr.  Willett,  where,  after  suture  of 
both  the  flexor  sublimis  and  profundus  tendons  in  the 
palui,  a  perfectly  movable  finger  was  obtained. 
Where,  however,  the  patient  is  old,  or  of  a  broken- 
down  constitution,  or  where  there  is  evidence  of 
extensive  destruction  or  of  adhesion  of  the  tendon, 
little  can  be  expected  from  suture,  and  in  the  case  of 
stiff  finger  amputation  is  then  attended  with  less  risk. 
Where  a  considerable  portion  of  tendon  has  been 
lost,  attempts  have  recently  been  made  by  Herr  Gluck 
to  restore  the  lost  part  by  uniting  the  divided  ends 
with  a  leash  of  catgut,  on  the  supposition  that  this  will 
become  organised,     lie  claims  successful  results. 

Kiiptiirc. — Subcutaneous  rupture  of  tendons  may 
occur  during  some  sudden  or  involuntary  action  of  the 


312  Manual  of  Surgery. 

muscles,  and  is  not  an  uncommon  accident  in  men 
beyond  the  middle  period  of  life.  It  is  most  frequent 
in  the  plantaris,  and  tendo  Achillis,  and  long  tendon 
of  tlto  biceps.  The  rupture  is  often  attended  with  an 
audible  snap,  and  with  a  sensation  to  the  patient  of 
having  been  struck,  followed,  in  the  case  of  the 
plantavis  or  Achilles  tendon,  by  lameness  or  inability 
to  walk,  and  some  local  bruising  and  extravasation. 
After  rupture  of  the  long  tendon  of  the  biceps  the 
short  head  contracts  into  a  hard  lump  on  putting  the 
muscle  into  action,  whilst  a  deficiency  is  felt  in  the 
situation  of  the  long  head.  Ivupture  of  the  inner 
head  is  said  generally  to  follow. 

Treatment. — The  parts  should  be  placed  at  rest  in 
such  a  position  as  to  approximate  the  ruptured  ends  as 
much  as  possible.  In  the  case  of  the  plantaris  or 
tendo  Achillis,  the  foot  should  be  fixed  in  full  exten- 
sion in  plaster  of  Paris,  and  the  leg  flexed  upon  the 
thigh  for  a  few  days  to  relax  the  calf  muscles. 
The  treatment  of  ruptured  biceps  has  not  hitherto 
been  very  successful.  In  an  otherwise  healthy  subject 
an  attempt  might  be  made  to  unite  it  by  suture  should 
it  ap})ear  possible  to  reach  the  ruptured  tendon 
without  opening  the  shoulder  joint. 

The  metJiod  of  union  of  a  tendon  when  ruptured 
subcutaneously  is  similar  to  that  wlu'ch  occurs  after 
tenotomy.  A  small  cell  exudation  is  formed  between 
the  divided  ends,  and  is  converted  into  filjrous  tissue, 
which  ultimately  cannot  be  distinguished  from  the  rest 
of  the  tendon. 

Dislocsitioii  of  a  tendon  from  \\n  sheath  or 
groove,  popularly  known  as  a  rick,  is  not  an  uncommon 
accident,  though  one  often  overlooked.  It  is  most 
liable  to  occur  to  the  til»ialis  jiosticus  and  the  peronei 
where  they  pass  behind  the  ankle,  the  long  tendon  of 
the  biceps  as  it  lies  in  the  bicipital  groove,  the  tendons 
in  the  ^ore-arm,  and  the  small  muscles  of  the  back  and 


2  'h  NO-S\  NO  VI T/S.  313 

of  tlio  neck.  It  is  usually  due  to  a  sudden  twist  or  a 
strain,  and  is  attended  by  pain  and  partial  or  complete 
loss  of  voluntary  movement  of  the  afl'ected  muscle, 
and  consequently  by  lameness,  or  stiffness  of  the  back 
or  neck,  etc.,  according  to  its  situation.  On  examina- 
tion, the  displaced  tendon  may  often  be  felt,  but  is 
liable  to  become  obscured  by  swelling  and  ecchymosis. 

Treatment. — A  dislocated  tendon,  though  readily 
reduced  by  manipulation,  is  difficult  to  kee[)  in  place. 
A  pad  and  bandage  should  be  applied,  and  the  part  in 
the  case  of  the  ankle  or  wrist  placed  in  a  well-fitting 
plaster  of  Paris  splint.  To  retain  the  tibialis  posticus 
or  peronei  in  their  place,  an  anklet  with  a  properly 
arranged  pad  must  subsequently  be  worn,  and  it  may 
even  be  necessary  to  divide  the  tendon,  or  to  pass  a 
tenotome  into  the  sheath  for  the  purpose  of  fixing  the 
tendon  to  the  sheath  by  inflammatory  adhesion. 

TcBio-s>iiovitis,  or  inflammation  of  sheaths  of 
tendons,  is  most  frequently  met  with  in  the  subacute 
form  and  in  the  extensors  of  the  thumb  and  wrist,  but 
it  may  occur  in  the  tendons  about  the  ankle,  in  the 
long  tendon  of  the  biceps,  etc.  It  is  usually  the  result 
of  excessive  exertion,  and  is  attended  by  a  localised 
swelling  over  the  afl'ected  tendons,  which  is  painful  on 
]iressure  and  movement,  and  gives  when  grasped 
during  action  of  the  part  a  characteristic  creaking  or 
crepitation.  The  inflammation  is  at  times  more  acute, 
and  may  terminate  in  sui)puration  ;  or  if  neglected  may 
become  chronic,  and  last  for  many  weeks  or  months. 

Treatment. — The  part  should  be  placed  at  rest  on  a 
splint,  or  a  plaster  of  Paris  or  a  Martin's  bandage  may 
be  applied.  When  more  acute  a  few  leeches  or  hot 
fomentations,  or  if  preferred  an  ice  bag  or  cold  lotions, 
may  be  necessary.  If  pus  forms,  free  incisions  should 
be  made,  followed  by  passive  movements  to  prevent 
adhesions  between  the  tendon  and  the  sheath.  When 
chronic,  blisters,   painting  with   iodine,  strapping  with 


314  Maaual  of  Suncerv. 

ammoniacum  and  mercury  j^laister,  or  Scott's  dressing 
followed  by  elastic  support,  sliould  be  tried. 

Paroiiycliia  teii€liiio<>>a  is  an  acute  septic 
inflammation  of  the  sheatli  of  a  tendon,  and  con- 
stitutes one  of  the  varieties  of  whitlow.  It  is 
most  common  in  the  thumb  or  one  of  the  fingers, 
but  is  occasionally  seen  in  the  toes.  It  is  generally 
due  to  a  poisoned  wound,  but  it  may  follow  a  mere 
scratch  or  prick  of  the  part  in  a  person  out  of  health, 
in  whom,  moreover,  it  may  occur  spontaneously.  Tlie 
inflammation,  which  is  of  an  erysipelatous  and  septic 
character,  may  begin  in  the  sheath  of  the  tendon  itself, 
or,  as  is  more  commonly  the  case,  in  the  tissues  super- 
ficial to  it,  or  in  the  periosteum  covering  the  phalanx. 
As  soon  as  the  sheath  is  involved  serious  consequences 
will  follow  if  a  timely  incision  to  relieve  tension  is  not 
made.  Thus,  in  consequence  of  the  unyielding  nature 
of  the  fibrous  tissue  forming  the  sheath,  the  blood-ves- 
sels of  the  tendon  may  be  strangled  by  the  inflammatory 
ejffusion,  and  the  tendon  die,  whilst  the  inflammation 
may  extend  into  the  palm,  and  under  the  annular 
ligament  to  the  nniscular  [ilanes  of  the  fore-arm.  When 
the  periosteum  is  attacked,  necrosis  of  the  phalanx 
and  destruction  of  one  or  more  phalangeal  joints,  or 
even  of  the  wrist  joint,  may  occur. 

Symptoms. — There  is  intense  pain,  often  shooting 
ujD  the  fore-arm,  hardness,  throbbing,  and  acute  tender- 
ness on  pressure  in  the  aflected  finge)-,  and  later,  in 
the  palm  ;  but  fluctuation  on  account  of  the  tenseness 
is  not  usually  present.  If  allowed  to  run  its  course, 
the  back  of  the  tinger  and  hand  becomes  red,  swollen, 
and  oedematous,  and  the  palm  infiltrated  and  tense  ;  an 
erysij)elatous  blush,  accompanied  by  oedema,  extends 
up  the  fore-arm  along  the  course  of  the  lymphatics, 
whilst  the  lymphatic  glands  become  tender  and 
enlarged.  Severe  constitutional  disturbance  is  often 
present,   and   the  patient   is   greatly  exhausted  from 


GANGLioy.  315 

pain  and  want  of  sleep,  and  maj  even  succumb  to 
blood  poisoning  or  septicaimia. 

Treatment. — The  surgeon  should  not  wait  for  fluc- 
tuation, but  as  soon  as  there  is  hardness  and  throl)biMg 
pain,  should  make  a  free  incision  in  the  middle  line 
of  the  finger  extending  into  the  sheath.  In  slighter 
cases,  where  the  inflammation  is  superficial,  the  sheath 
should  not  be  opened.  The  hand  should  be  then 
placed  on  a  splint,  well  raised  by  a  sling,  and  a  large 
poultice,  or  some  hot  moist  antiseptic  dressing,  if  pre- 
ferred, applied.  In  severe  cases  nothing  will  be  found 
to  give  greater  relief  than  placing  the  hand  and  fore- 
arm in  the  arm  bath  for  several  hours,  the  temperature 
of  the  water  being  kept  up  the  while.  iSTot  withstanding 
this,  if  suppuration  ensues  in  the  palm,  back  of  the  hand, 
or  fore-arm,  early  and  free  incisions  are  impeiative. 
Dead  bone  must  be  removed  when  loose,  and  in  severe 
neglected  cases  am^nitation  may  be  necessary  to  save 
the  patient's  life.  A  saline  or  calomel  purge  is 
usually  required  at  the  onset,  with  opium  in  some 
form  to  relieve  the  pain.  After  suppuration  has 
occurred,  a  tonic  and  supporting  treatment  is  called 
for.  Passive  exercises  may  be  required  for  long 
periods  after  healing  to  prevent  stiffening  of  the 
fingers  or  wrist. 

Oaiigliou  Is  a  simple  or  compound  cyst  formed 
in  connection  with  a  tendon.  A  simple  ganylioii  con- 
sists of  a  closed  sac  composed  of  fibrous  tissue  lined 
with  pseudo-epithelium,  and  containing  a  clear  gela- 
tinous colloid  m.aterial.  The  sac  does  not  communicate 
with  the  interior  of  the  sheath  of  the  tendon,  and 
consequently  is  non-adherent  to  the  tendon.  It  is 
not  known  exactly  how  these  ganglia  are  producecL 
They  are  variously  ascribed  to  a  protrusion  of  the 
synovial  lining  through  the  sheath,  with  subsequent 
obliteration  of  the  neck  of  the  pouch  thus  formed ; 
to  a  cystic  degeneration  of  the  ceils  in  the  synoviid 


3i6  Manual  of  Sukglkv. 

fringes  ;  or  to  a  dilatation  of  the  subsynovial  follicles 
described  by  Joselin.  Tliey  are  most  frequently  met 
with  on  the  extensor  tendons  at  the  back  of  the 
wrist ;  more  I'urely  on  the  flexors,  either  in  front  of 
the  Avrist  or  near  the  Aveb  of  the  lingers,  and  on  the 
tendons  on  the  dorsum  of  the  foot.  They  form  smooth, 
globular,  or  sometimes  lobulated,  circumscribed, 
movable  swellings,  evidently  connected  with  a  tendon. 
They  are  semitiuctuating,  or  tense,  and  almost  solid- 
feeling,  often  translucent,  and  non-adherent  to  the 
skin.  In  size  they  vary  from  a  hemp  seed  to  a 
walnut,  or  even  larger.  They  are  generally  painless, 
but  give  rise  to  a  sensation  of  weakness  in  the  wrist 
or  lingei*s.  Simple  ganglia  may  be  simulated  by 
pouch-like  protrusions  of  the  synovial  membranes  of 
the  carpus  and  tarsus,  from  which  they  may  generally 
be  distinguished  by  the  pouches  liaving  deep  connec- 
tions, and  having  no  apparent  relation  with  any  tendon, 
and  by  the  synovial  membrane  appealing  swelled  in 
other  places. 

Treatment. — They  should  be  broken  by  pressure 
of  the  thumbs  or  punctured  with  a  tenotome,  and  their 
contents  S(|ueezed  out,  and  firm  pressure  applied  by 
means  of  a  piece  of  sheet  lead,  a  pad  of  lint,  and  a 
bandage.  Should  they  refill,  a  second  puncture  should 
be  made,  the  interior  of  the  cyst  scarified  with  the 
]»oint  of  the  tenotome,  and  pressure  reapplied.  This 
failing,  a  seton  should  be  passed  through  the  cyst  wall, 
or  the  cyst  dissected  out. 

A  comjwund  ganglion  is  a  dilatation  with  thin 
serous  fluid  of  the  sheaths  of  several  tendons,  with 
complete  or  partial  obliteration  of  the  portions  of  the 
sheaths  in  contact.  The  sac  generally  becomes  slightly 
thickened,  and  soft  and  velvety  on  its  internal  aspect, 
so  that  it  resembles  a  mucous  rather  than  a  serous 
membrane.  Melon-seed  bodies,  like  those  contained 
in  some  bursae,  are  generally  found    in    the   interior. 


Affections  of  Fasc/.f..  317 

Although  it  may  occur  in  other  situations,  it  is  more 
common  in  connection  with  the  flexor  tendons  as 
they  pass  under  the  annular  ligament,  and  is  then 
known  as  the  palmar  bursal  ganglion.  This  generally 
forms  an  elongated  swelling,  constricted  at  its  centre 
by  the  annular  ligament,  and  extending  into  the  palm 
and  a  variable  distance  up  the  fore-arm.  Fluctuation 
can  be  obtained  by  pressing  alternately  above  and 
below  the  annular  lii^ament.  Sometimes  this  ^ancflion 
involves  the  tendons  of  the  thumb  or  little  finger,  or 
both. 

Treatment. — Painting  with  liniment  of  iodine, 
blisters,  and  pressure  should  first  be  tried,^  although 
they  seldom  efTect  a  cure,  as  all  operative  procedures 
are  attended  with  much  risk,  and  should  only  be 
undertaken  as  a  last  resource.  Several  methods  of 
operating,  as  puncture,  incision  in  the  palm,  division 
of  the  ligament,  etc.,  have  been  advised.  I  have 
seen  all  attended  with  success.  But,  on  the  other 
hand,  I  have  further  seen  all  of  them  followed  by 
diffuse  suppuration,  glueing  together  of  the  tendons, 
abscesses  amongst  the  muscles  of  the  fore-arm,  and  even 
by  death.  The  operation  that,  in  my  opinion,  is  attended 
with  the  least  danger  and  the  best  success,  is  an 
antiseptic  incision  both  above  and  below  the  ligament, 
with  evacuation  of  the  melon-seed  bodies,  and  free 
drainage.  The  hand  and  fore-arm  should,  of  course, 
be  placed  on  a  splint. 

Injuries  and  Diseases  of  Fascia. 

Rupture. — The  fascia,  as  that  of  the  front  wall 
of  the  abdomen^  or  that  in  front  of  the  thigh,  may  be 
ruptured  subcutaneously  during  some  sudden  or  violent 
effort.  Such  a  rout  in  the  fascia  is  liable  to  remain 
ununited,  allowing  the  muscles  which  it  ought  to 
confine  to  start  forward  during  contraction.  Protru- 
sions of  this  nature  through  the  abdominal  fascia  may 


3i3  Manual  of  Surcerv. 

readily  be  mistaken  for  ventral  hernia.  Some  form 
of  elastic  support  should  be  applied. 

I>ui>u>'ti'cii's  coiitraetioii,  or  contraction  of 
tlie  palmar  fascia. — The  cause  of  this  affection  is 
not  very  evident ;  it  has  been  variously  ascribed  to 
gout  and  rheumatism,  and  to  habits  oi-  occupations 
necessitating  flexion  of  the  fingers  or  mechanical 
pressure  on  the  palm  of  the  hand.  It  is  more  common 
in  men  than  in  women,  and  is  said  to  occur  more  often 
in  the  upper  and  middle  classes  than  in  the  lower. 

Patliology. — The  contraction  occurs  in  that  portion 
of  the  fascia  which  is  prolonged  on  to  the  sheath  of 
the  flexor  tendons  and  is  inserted  into  the  periosteum 
of  the  second  phalanx.  The  bones,  ligaments,  and 
tendons  are  not  afiected. 

Sympfoms. — It  generally  begins  in  that  part  of  the 
fascia  which  is  continued  on  to  the  little  or  ring  finger, 
whilst  later  it  may  involve  that  of  the  middle  finger 
also,  and  in  rare  instances  the  fascia  attached  tc 
all  the  fingers  and  even  the  thumb.  The  affected 
fingers  are  drawn  gradually  more  and  more  down- 
wards towards  the  palm,  till  they  become,  in  severe 
cases,  firmly  fixed,  and  in  contact  with  it.  The  con- 
tracted portions  of  the  fascia  form  prominent  ridges 
running  from  the  affected  fingers  a  variable  distance 
into  the  palm,  and  can  be  made  more  tense  on  trying 
to  strnighten  the  fingers.  Where  the  afiection  has 
existed  some  time  the  skin  becomes  adherent  to  the 
fascia  and  is  thrown  into  transverse  puckers.  It  may 
be  distinguislied  from  a  contracted  tendon  by  the 
latter  forming  a  tense  cord,  which  can  be  traced  up- 
wards under  the  annular  ligament,  and  by  the  tissues 
of  the  i)alm  appearing  natural  and  not  puckered. 
Froui  arthritis  deformans  it  may  be  diagnosed  by  the 
joints  being  unaffected. 

Treatment. — In  the  incipient  stages  steps  should 
be  made  to  prevent  the  contiaction  increasing  by  the 


Bursitis.  319 

U30  of  some  of  the  linger  s])lints  that  have  been  in- 
vciiited  for  the  purpose.  When  confirmed  it  is  best 
treated  by  diAdsion  and  subsequent  exteiasion. 

Much  discussion  has  of  late  taken  place  as  to 
whether  a  single  division  or  multiple  subcutaneous 
divisions  of  tlie  fascia  should  be  made.  The  writer, 
from  an  experience  of  both,  has  no  hesitation  in  recom- 
mending the  latter.  But  a  very  small  tenotome  must 
be  used,  and  great  care  taken  not  to  wound  the  skin. 
The  liand  and  fore-arm  should  be  afterwards  placed  on 
a  splint,  and  the  lingers  gradually  extended  by  elastic 
tension.  (For  contraction  of  the  plantar  fascia  see 
Talipes,  page  338.) 

Diseases  op  Burs^. 

BursaB,  whether  naturally  existing  as  over  the 
patella,  or  olecranon,  or  formed  adventitiously  from 
irritation  or  constant  pressure  on  a  part,  as  under  a 
neglected  corn  or  over  the  outer  side  of  the  foot  in 
talipes  varus,  are  liable  to  become  acutely  or  chroni- 
cally inflamed. 

Acute  biBB'sitis,  though  aj)parently  sometimes 
arising  spontaneously,  can  generally  be  traced  to  a 
blow,  fall,  or  other  injury.  It  is  attended  with  the 
usual  signs  of  acute  inflammation,  and  is  very  apt  to 
run  on  into  suppuration,  and,  if  a  timely  incision  is 
not  made,  to  become  diffuse,  and  of  a  plilegmonous 
character. 

Treatment. — A  few  leeches,  or  an  ice  bag  may 
be  applied  if  seen  early,  but  a  free  incision  should  be 
made  as  soon  as  there  is  any  evidence  of  suppuration. 

CBii'oiiic  bursitis. — Chronic  inflammation  may 
give  rise  to  several  different  pathological  conditions,  in 
all  of  which  the  burs?e  are  more  or  less  enlarged 
and  generally  contain  serous  fiuid.  (1)  Their 
walls  are  usually  Ijut  slightly,  if  at  all,  thickened, 
and   the   fiuid   is    merely   an  increase   of   the  normal 


320  Manual  of  SuKcr.Rv, 

bursal  secretion.  They  then  appear  as  more  or  less 
globular,  fluctuating,  tense,  and  sometimes  flaccid 
swellings,  and  when  superficial  may  be  translucent. 
(2)  In  other  cases  their  walls  become  distinctly  thick- 
ened, whilst  small,  flattened,  sharp-edged,  ovoid,  or 
sometimes  irregularly  shaped  masses  of  fibrin  known 
as  melon-seed  bodies,  are  found  floating  in  a  serous  or 
dark-coloured  fluid  in  their  interior.  The  formation 
of  these  bodies  has  been  attributed  to  the  moulding  of 
fibrinous  deposits  by  constant  movement,  to  the 
break ing-olF  of  thickened  synovial  fringes  lining  the 
bursa,  and  to  changes  in  blood  which  may  have 
been  extravasated  into  the  interior  of  the  bursa. 
Again,  in  place  of  melon-seed  bodies,  or  together  with 
them,  fibrous  cords  may  be  found  stretching  across  the 
cavity.  The  presence  of  melon-seed  bodies  may  often 
be  detected  by  the  crackling  sensation  they  communi- 
cate to  the  touch  when  the  bursa  is  handled.  (3)  The 
walls  may  become  greatly  thickened  from  inflamma- 
tory infiltration,  and  probably  in  part  from  the  con- 
centric deposit  of  fibrin  in  their  interior.  A  small 
central  cavity  usually  remains,  but  in  some  instances 
they  become  solid  throughout.  In  either  case  they 
give  rise  to  a  firm  non-elastic  solid-feeling  tumour, 
and  are  often  productive  of  great  inconvenience. 

The  treatment  will  necessarily  somewhat  vary  in 
detail  according  to  the  situation  of  the  bursa.  (See 
Diseases  of  Special  Bursa?.)  In  simple  enlargement, 
painting  with  tincture  or  liniment  of  iodine,  or  firm 
and  equable  pressure,  will  often  disperse  them.  If  this 
fails  they  should  be  punctured  with  a  small  trocar 
arnl  tlie  fluid  evacuated,  any  melon-seed  bodies  con- 
tained in  them  squeezed  out,  and  pressure  applied. 
Wlien  creat  thickenincj  of  the  walls  has  occurred,  or 
the  buisa  lias  become  solid,  the  only  treatment  is  to 
dissect  it  out. 


Bursitis.  321 

Diseases  of  Special  Burs.e. 

The  bursa  patcllcC  is,  of  all  the  bursse,  the  one 
most  often  affected.  Chronic  enlargement,  and,  some- 
what less  frequently,  acute  inflammation,  are  very 
often  met  with ;  and  from  the  frequency  with  which 
they  occur  in  housemaids  and  others  who  have  much 
kneeling,  are  known  as  the  housemaid's  knee.  When 
chronically  enlarged,  the  bursa  ai)pears  as  a  prominent 
tumour  in  front  of  the  patella  and  ligamentum  patella3, 
tense,  flaccid  or  solid  to  the  touch,  according  to  the 
degree  of  distension  and  condition  of  its  walls.  When 
acutely  inflamed  it  is  liable  to  be  mistaken  for  disease 
of  the  knee  joint,  the  more  so  should  the  inflammation, 
as  is  sometimes  the  case,  become  diffuse  and  burrow 
around  tlie  joint  under  the  expansion  of  the  vasti. 
In  the  one,  hoAvever,  the  patella  will  be  behind 
the  swelling,  whilst  in  the  other  it  will  be  in  front 
of  it. 

Treatment. — In  simple  enlargement,  should  paint- 
ing with  iodine  or  pressure  fail,  the  bursa  should  be 
punctured,  the  fluid  let  out,  and  the  joint  firmly 
strapped  and  placed  on  a  back  splint  for  a  few  days. 
When  solid  or  much  thickened,  a  vertical  incision 
should  be  made  over  it  and  the  bursa  dissected  out. 
As  the  capsule  of  the  joint  is  very  thin,  and  may  be 
easily  opened,  care  must  be  taken  during  the  dissection 
to  hold  the  knife  close  to  the  bursa,  and  not  to  drag  the 
tissues  too  forward.  Acute  inflammation  should  be 
treated  on  the  general  principles  already  indicated. 
Should  suppuration  occur,  a  free  vertical  incision 
should  be  made  over  tke  centre  of  the  patella ;  or,  if 
the  suppuration  has  become  diffuse,  two  lateral  in- 
cisions will  ensure  a  better  drain. 

Bursa  over  the  olecrauou,  called  the  miner's 
bursa   from  the  frequency  wivh  which  it  is  enlarged  in 
miners,  is  particularly  apt,  after  a  blow  or  fall  upon 
V— 21 


322  Manual  of  Surgery. 

the  elbow,  to  become  acutely  inflamed.  The  inflam- 
mation is  generally  of  a  severe  phlegmonous  charactei', 
and  extends  a  considerable  distance  above  and  below 
the  back  of  the  elbow  joint,  for  disease  of  which  it 
may  be  mistaken.  The  freedom  of  the  joint  in  front, 
and  the  presence  of  a  soft  spot  over  the  situation  of 
the  olecranon,  are  points  which  serve  for  the  diagnosis. 
Free  incisions  should  be  made  as  soon  as  suppuration 
occurs,  and  the  arm  put  at  rest  on  an  angular  splint. 
Kecrosis  of  a  small  portion  of  the  olecranon  is  not  an 
uncommon  result.  The  dead  bone  should  be  removed 
when  loose,  great  care  being  taken  not  to  injure  the 
elbow  joint. 

The  bti&'sa  beneath  the  seiuiiiieiiBbraii- 
Oiiiiis  frequently  becomes  enlarged,  giving  rise  to  a 
tense  or  scmifluctuating,  and  usually  globular  or  ovoid 
swelling  in  the  popliteal  space.  The  absence  of 
pulsation  and  of  signs  of  inflammation,  and  the  facts 
that  the  inner  hamstring  tendons  can  be  traced  over 
it,  and  that  it  becomes  flaccid  or  disappears  on  flexing 
the  knee,  should  prevent  it  being  mistaken  for  other 
swellings  in  this  region.  Painting  with  iodine,  firm 
strapping,  or  blisters  will  usually  disperse  it.  Should 
these  fail,  puncture  or  antiseptic  incision  must  be 
resorted  to,  operations,  however,  that  should  never  be 
undertaken  lightly,  as  the  bursa  often  communicates 
with  the  knee  joint. 

The  bursa  over  the  tuber  isehii  is  apt  to 
become  chronically  eidarged,  and  its  walls  thickened, 
in  persons  whose  occupations  necessitate  long  sitting, 
and  is  then  known  as  the  coachman's  or  weaver's  bot- 
tom. It  is  usually  a  source  of  great  annoyance,  and 
generally  requires  dissecting  out. 

Tlie  bursa  over  th<^  ^jreat  trocliantcr  may, 
when  enlarged  and  inflamed,  simulate  hip  disease.  It 
may  be  distinguished  from  it  by  the  absence  of  the 
chaiacteristic  deformity  of  the  latter  aflection  ajid  of 


Bursitis.  323 

dead  bone  or  any  communication  "wdtli  the  joint  on 
opening  the  inflamed  bursa. 

The  biu'sa  under  the  tendon  of  the  psoas, 

when  enlarged,  produces  a  deep-seated,  fluctuating 
swelling  in  the  groin.  It  may  be  mistaken  for  a  psoas 
abscess  or  an  aneurism,  but  the  absence  of  spinal 
disease  and  signs  of  suppuration  in  the  one  case,  and 
the  fact  that  the  artery  is  above  the  swelling  in  the 
other,  should  generally  serve  to  distinguish  them.  It 
should  be  remembered  that  the  bursa  may  communicate 
with  the  hip  joint,     (For  bunion  see  Hallux  valgus.) 


324 


VL     ORTHOPEDIC   SURGERY. 

W.  J.  Walsham. 

Wry  Neck. 

Wry  neck  or  torticollis  is  a  distortion  produced 
by  tlie  conti'action  chiefly  of  the  sterno-mastoid,  and  to 
a  less  extent  of  the  trapezius  and  scalene  muscles.  A 
somewhat  similar  distortion  may  be  produced  by 
strumous  and  rheumatic  disease  of  the  cervical  verte- 
brae, or  by  cicatricial  contraction  following  burns  or 
sloughing  of  the  neck,  or  by  paralysis  of  certain 
muscles.  Such,  however,  are  described  in  the  articles 
on  Diseases  of  the  Spine,  etc. 

Causes. — Wry  neck  may  be  congenital  or  acquired. 
When  congenital,  it  has  been  attributed  to  disease  of 
the  nervous  system  producing  a  spastic  contraction  of 
the  affected  muscles,  to  a  malformation  in  utero,  or  to 
some  injury  of  the  neck  inflicted  at  birth.  The 
acquired  form  may  be  the  result  of  the  head  having 
been  held  for  a  long  time  in  a  distorted  position,  as 
from  stiff  neck  after  cold  or  injury,  or  from  inflamma- 
tion of  the  cervical  glands  after  scarlet  fever,  etc. ;  or 
it  may  be  the  result  of  hysteria,  or  of  spasm  of  the 
muscles  due  to  irritation  of  the  spinal  accessory  nerve 
from  some  central  nerve  aflection. 

PatJiology. — When  the  deformity  is  of  some  stand- 
ing the  ligaments  are  shortened,  and  the  intei-vertebral 
cartilages  compressed  on  the  affected  side ;  whilst  in 
severe  cases  the  bodies  of  the  cervical  vertebrae  undergo 
rotation  and  slight  lateral  compression,  and  their 
articular  processes  are  altered  in  shape  and  direction. 
The  affected  muscles  undergo  more  or  less  fibrous 
degeneration. 


lVj?y  N^ECK.  325 

Symptoms. — The  head,  supposing  the  right  sterno- 
niastoid  to  be  affected,  is  drawn  forwards  and  towards 
the  right  shoulder,  and  at  the  same  time  rotated  so 
that  the  chin  points  to  the  left.  The  left  side  of  the 
neck  is  unnaturally  convex,  the  right  unnaturally 
concave,  whilst  the  mastoid  on  that  side  stands  out 
prominently,  and  both  the  sternal  and  clavicular 
portions  of  it  can  be  felt.  The  features  on  the  affected 
side  are,  in  the  congenital  form,  markedly  smaller  tlian 
on  the  other.  In  severe  and  long-standing  cases  slight 
elevation  of  the  right  shoulder  and  scapula,  and 
some  lateral  curvature  of  the  dorsal  spine,  are  generally 
present. 

The  diagnosis  is  usually  quite  easy.  From  cervical 
caries,  wry  neck  may  be  distinguished  by  the 
absence  of  the  characteristic  signs  of  the  former,  i.e. 
pain  on  movement  and  on  percussing  the  head  or 
vertebrae,  rigidity  and  thickening,  the  patient's  in- 
ability or  unwillingness  to  rotate  his  head,  and  the 
tendency  of  the  chin  to  drop  forward.  It  is  also 
important  to  diagnose  the  spasmodic  and  hysterical 
from  the  non-spasmodic  and  congenital.  In  the  non- 
spasmodic  the  sterno-mastoid  becomes  tense  on  trying 
to  straighten  the  head,  in  the  spasmodic  it  gi-adually 
yields ;  in  the  non-spasmodic  it  becomes  relaxed  on 
bending  the  head  towards  the  affected  side,  but  in  the 
spasmodic  contracted.  The  history  will  further 
distinguish  the  congenital  from  the  other  forms.  In 
the  hysterical  there  will  be  other  signs  of  hysteria, 
and  the  head  can  be  straightened  under  chloroform. 

Treatment. — In  the  congenital  form,  except  in  very 
slight  cases  in  infants  where  exercises  and  manipula- 
tion alone  may  suffice,  division  of  the  sterno-mastoid 
is  necessary.  This,  along  with  manipulation  and 
exercises,  will  often  be  sufficient ;  but  in  severe  cases 
instrumental  treatment  will  also  be  required.  The 
sterno-mastoid  is  best  divided  immediately  above  the 


326 


Manual  of  Surgery, 


clavicle,  as  liere  it  is  chiefly  tendinous,  and   further 
removed    from    the  important    structures    wliicli    lie 
beneath  it.     A  puncture  should  be  made  to  the  inner 
side    of    the    tendon,    and    the    sheath  having   been 
opened,  a  blunt  director  should  be  passed   beneath  the 
muscle  and   the  division  made  towards  the  skin  with 
a  blunt-pointed    tenotome    guided    by    the    director. 
Tense    bands   of    contracted    cervical  fascia  will  now 
generally  start  up.     These  it  is  not 
safe    to    divide,    but    they    may    be 
made  to   yield  by  forcibly  rotating 
the   head  and   pressing  upon  them 
wdth    the    fingers.       The   puncture 
should  be  allowed  to  heal  with  the 
head  in  the  deformed  position,  which 
it  will    do   in    two   or   three   days. 
I  usually  put  the  patient    through 
a    series     of     exercises,    consisting 
of  various  active  and  passive  move- 
ments    of    the     head     and     neck, 
for   a   fortnio-ht    or   so   before    the 
operation,  go    on  with   them  again 
when  the  wound  has  healed  till  the 
deformity    has    disappeared,    and   I 
advise  their  continuance    for   some 
time  afterwards   to   prevent   a   relapse.       In    severer 
cases    indiarubber   bands,    so    arranged    as    to    make 
traction    in    the    desired    direction,   are    used    in    the 
intervals  between  the  exercises  and  at  night.     Where 
an  instrument  is  necessary,  I  prefer  the  one  shown 
in     the     accompanying     woodcut     (Fig.    69).        The 
spasmodic    form    is    often    very    intractable.      When 
such  remedies  as  bromide  of  potassium,  Indian  hemp, 
or  conium  have  failed,  the  spinal  accessory  nerve  may 
be  stretched.     It  is  readily  found  at  the  spot  where  it 
enters  the  sterno-mastoid,  the   posterior  belly  of  the 
digastricus,  under  which  it  previously  emerges,  serving 


Fig.  69.  — InstriTinent 
for  Wry  Neok  with 
Cog-wheel  Action. 


Scoliosis.  327 

as  a  good  guide  to  it.  In  this,  as  in  tlie  liysterical 
form,  the  sterno-mastoid  should  not  be  divided.  T 
have  obtained  the  best  success  in  hysterical  cases 
by  placing  tlie  head  in  the  straight  position  in  a  poro- 
plastic  collar,  whilst  giving  hysterical  remedies. 

Scoliosis. 

Scoliosis,  or  lateral  curvature,  is  a  compli- 
cated distortion  in  which  the  spine  forms  two  or 
more  lateral  curves  with  their  convexities  in  opposite 
directions  ;  whilst  the  vertebrae  involved  in  the  curves 
are  rotated  on  their  vertical  axis,  so  that  the  spinous 
processes  turn  to  the  concavity  of  the  curves.  It  ia 
more  common  in  the  young  than  in  the  old,  in  girls 
than  in  boys,  and  in  the  upper  and  middle  classes  than 
in  the  lower.  Although  most  frequently  met  with  in 
delicate  and  rapidly  growing  girls  from  fifteen  to 
twenty-one,  wanting  in  general  muscular  strength,  it 
is  occasionally  seen  in  those  who  are  strong,  robust, 
and  country-bred.  It  may  also  occur  as  one  of  tlie 
complications  of  rickets,  and  as  the  result  of  the  falliiig 
in  of  one  side  of  the  chest  consequent  upon  contraction 
following  empyema,  and  in  very  rare  instances  as  a 
congenital  deformity. 

Causes. — When  the  normal  spine  is  inclined 
laterally,  the  pressure  on  the  intervertebral  cartilages 
and  articular  processes  is  increased  on  one  side  and 
diminished  on  the  other.  If  this  unequal  pressure  is 
continued  for  long  periods,  the  articular  cartilages 
under  certain  conditions  will  remain  permanently 
compressed,  while  the  articular  processes  become 
altered  in  direction  and  shape ;  in  this  way  a 
permanent  curve  either  to  the  right  or  to  the  left  may 
be  produced.  Any  circumstance,  therefore,  that 
causes  the  spine  to  incline  for  long  periods  to  one  or 
other  side  may  be  regarded  as  the  exciting  cause  of 
lateral  curvature ;  but  it  must  not  be  lost  sight  of  that 


328  Manual  of  Surgefv. 

for  the  exciting  causes  to  become  operative,  certain 
predisposing  conditions  appear  to  be  necessary.  These 
may  be  summed  up  as  want  of  tone  in  the  muscles 
and  ligaments,  or  structural  weakness  of  the  bones 
such  as  may  be  induced  by  (1)  heredity,  (2)  general 
debility,  (3)  the  strumous  diathesis,  (4)  rickets,  (5)  rapid 
growth,  etc.     The  exciting  causes  may  be  classed  as  ; 

1.  Any  condition  causing  2)^f^nanent  or  habitual 
obliquity  of  tJie  pelvis,  and  the  consequent  throwing 
of  the  spine  over  to  one  side,  such  as  a  natural 
inequality  in  the  length  of  the  legs,  knock  knee, 
flat  foot,  congenital  dislocation  of  the  hip,  use  of 
a  wooden  leg,  habit  of  standing  on  one  leg,  sitting 
cross-legged,  etc. 

2.  A  one-sided  position  of  the  body  in  sitting  or 
lying  down,  or  induced  by  following  certain  employ- 
ments such  as  nur.sing  a  child,  carrying  heavy 
weights,  etc. 

3.  Contraction  of  one  side  of  the  thorax  following 
empyema,  etc. 

4.  Unilateral  contractions  of  the  spinal  muscles 
induced  by  paralysis  of  the  opposing  muscles. 

There  are  various  other  theories  as  to  the  cause  of 
lateral  curvature,  of  which  space  will  not  permit  the 
discussion,  such  as  contraction  of  the  spinal  muscles 
on  one  side  induced  either  by  disease  of  the  nervous 
system  or  by  debility  of  tlie  muscles  on  the  opposite 
side,  unequal  contraction  of  the  serratus  magnus,  etc. 

Pathology. — In  a  typical  example  [see  Fig.  70) 
the  spine  presents  a  double  curvature,  an  upper 
dorsal  and  a  lower  lumbar,  or,  more  correctly  speak- 
ing, a  dorso-lumbar.  The  dorsal  has  generally  its 
convexity  to  the  right,  the  lumbar  its  convexity  to 
the  left.  The  curvature  which  depends  directly  upon 
the  exciting  cause  is  called  the  primary ;  and  the 
other  which  forms  in  the  opposite  direction  to  counter- 
balance the  loss  of  equilibrium  occasioned  by  the  first, 


Scoliosis. 


329 


the  secondary  or  compensating.  Either  the  dorsal  or 
the  lumbar  may  be  the  primary  curve,  and  vice  versd. 
less  commonly  the  spine  forms  an  apparently  single 
/jurve,  with  the  con- 
vexity either  to  the 
right  or  to  the  left ; 
but  in  such  cases  there 
is  always  a  slight  com- 
pensating curve  above 
and  below,  although 
these  may  not  be  ob- 
served externally.  In 
other  instances  there 
may  be  four  or  even 
five  curves  duly  com- 
pensating each  other. 
The  intervertebral  car- 
tilages, and  to  a  lesser 
extent  the  bodies  of  the 
vertebrae  involved  in 
the  curve,  are  com- 
pressed wedge-wise,  the 
base  of  the  wedge  look- 
ing towards  the  con- 
vexity of  the  curve ; 
whilst  the  articular 
processes  are  contracted 
and  flattened  on  the 
concave  side  and  elon- 
gated on  the  convex. 
In  addition  to  the 
lateral     deviation,     the 

vertebrae  forming  the  curves  are  rotated  on  their 
vertical  axis,  so  that  the  front  of  the  bodies  looks 
towards  the  convexity,  and  the  apices  of  the  spinous 
processes  towards  the  concavity  of  the  curve.  Asa 
consequence  of  this  rotation,  although  there  may  be 


Fig.  70.— Lateral  Curvature  of  the 
Spine.  (From  a  specimen  iu  St. 
Bartholomew'sHospitaOIuseum.) 


330  Manual  of  Surgery. 

considerable  lateral  deviation  of  the  bodies  of  tlie 
vertebrse,  the  apices  of  the  spinous  processes  may  be 
out  little  deflected  from  the  middle  line.  The  cause 
of  this  rotation  has  been  variously  explained.  The 
theory  which  has  perhaps  found  most  favour,  and  to 
which  only  space  will  permit  of  reference,  is  that  of 
Dr.  Judson,  of  iSTew  York,  "It  is  based  on  the  fact 
that  the  posterior  portion  of  the  vertebral  column, 
being  a  part  of  the  dorsal  parietes  of  the  chest  and 
abdomen,  is  confined  in  the  median  plane  of  the 
trunk,  whilst  the  anterior  portion  of  the  column  pro- 
jecting into  the  thorax  and  abdominal  cavities,  and 
devoid  of  lateral .  attachments,  is  at  liberty  to,  and 
physiologically  does,  move  to  the  right  and  left  of  the 
median  plane."  As  a  result  of  the  lateral  compression 
and  of  the  rotation  of  the  vertebrae  the  transverse 
processes  and  ribs  on  the  convex  side  are  abnormally 
separated  from  one  another  and  are  carried  back- 
wards, whilst  those  on  the  concave  side  are  closer 
toijether  than  natural  and  are  carried  forwards.  The 
ribs,  moreover,  on  the  convex  side  are  more  hori- 
zontal than  natural,  and  their  angles  form  a  hump 
in  the  dorsal  region  and  cause  the  scapula  to  be 
raised  and  to  project,  while  those  on  the  concave 
side  run  more  obliquely  than  natural,  so  that  in 
severe  cases  they  may  be  in  contact  with  the  iliac  crest. 
There  is  thus  much  distortion  of  the  thorax  and  undue 
prominence  of  the  left  breast.  The  pelvis,  except 
in  cases  of  rickety  curvature,  is  not,  as  a  rule,  de- 
formed, although  in  severe  lumbar  curvature  it  may 
be  obliquely  placed.  Of  the  condition  of  the  muscles 
in  the  earlier  stages  very  little  is  known ;  in  the 
later  they  have  been  found  atrophied  and  undergoing 
fatty  degeneration. 

Syiiiptoiiis. — The  incipient  stages  of  lateral 
curvature  are  frequently  overlooked,  and  it  is  often 
not  until  it  has  become  well  marked  and   permanent 


Scoliosis.  331 

that  the  surgeon  is  consulted.  Ofttimes  the  patient 
is  brought  to  him  for  the  shoulder  or  hip  growing  out, 
for  round  shoulders,  or  pain  in  the  back,  the  parents 
perhaps  declaring,  if  the  question  is  asked,  that  the 
spine  is  quite  straight.  In  such  cases,  and  whenever 
there  is  a  suspicion  of  lateral  curvature,  a  thorough 
examination  in  drill  posture,  with  the  l>ack  fully  ex- 
posed, should  be  made.  In  the  earlier  stages  there 
may  be  but  little  deviation  of  the  apices  of  the 
spinous  processes,  and  what  little  there  is  may  be 
made  to  disappear  on  suspending  the  patient  or  placing 
him  in  the  prone  position.  There  may  be  a  slight 
projection  of  one  scapula,  however,  or  an  apparent 
prominence  of  one  iliac  crest,  or  it  may  be  a  mere 
want  of  symmetry  on  the  two  sides  of  the  sjiine, 
which  may  best  be  detected  by  placing  the  patient 
on  a  low  seat  and  looking  down  the  back  from 
above,  whilst  along  with  this  there  will  usually  be 
more  or  less  obliteration  of  the  normal  lumbar  curve 
and  a  general  tendency  to  stoop.  In  severer  cases 
the  deformity  will  generally  be  unmistakable,  although 
the  amount  of  deviation  of  the  spinous  processes,  and 
prominence  of  the  scapula  and  iliac  crest  will  vary  con- 
siderably, according  to  the  character  of  the  curve.  In 
the  common  form,  in  which  there  is  a  longer  dorsal  curve 
with  its  convexity  to  the  right,  and  a  shorter  lumbar 
with  its  convexity  to  the  left,  the  right  shoulder  is 
generally  elevated,  and  the  angle  of  the  right  scapula 
and  right  crest  of  the  ilium  and  left  breast  are  pro- 
minent, whilst  the  backward  rotation  of  the  lumbar 
transverse  processes  on  the  left  side  cause  the  lumbar 
muscles  to  protrude  and  give  a  greater  sense  of  resis- 
tance on  pressing  on  this  side  of  the  spine.  In  the 
long  and  apparently  single  curve  the  deformity  is 
often  extreme.  The  ribs  on  the  convex  side  project 
prominently  backwards  and  form  a  hump  in  the  dorsal 
region,  and  cause  great  elevation  of  the  corresponding 


332  Manual  of  Surgery. 

shoulder  and  projection  of  the  scapula,  whilst  those 
on  the  left  side  are  huddled  together  and  depressed, 
in  some  instances  overlapping  the  crest  of  the  ilium. 
At  times  the  single  curve  is  confined  chiefly  to  the 
lumbar  region ;  the  prominence  of  the  crest  of  the 
ilium  on  the  concave  side,  and  the  backward  rotation 
of  the  lumbar  transverse  processes  and  the  conse- 
quent projection  of  the  spinal  muscles,  are  then  the 
most  marked  feature  ;  whilst  at  other  times  the  curve 
is  limited  to  the  upper  dorsal  region,  the  chief  cha- 
racters then  being  the  projection  of  the  scapula  on 
the  convex  side  and  the  prominence  of  the  trapezius, 
which  may  form  an  apparent  tumour  and  give,  as 
pointed  out  by  Mr.  Adams,  a  doubtful  sense  of  fluc- 
tuation. 

Diag^nosis. — Lateral  curvature  may  have  to  be 
distinguished  from  hysteria  and  from  caries  of  the 
vertebrae  attended  with  lateral  instead  of  angular 
deviation.  In  hysteria  there  is  no  rotation,  and  the 
curve,  although  apparently  permanent,  will  generally 
disappear  on  assuming  the  diving  position  and  bending 
the  back  with  the  knees  straight  till  the  finsrers  touch 
the  ground.  Other  evidences  of  hysteria  will  also 
commonly  be  detected,  but  if  any  doubt  remains  an 
anaesthetic  should  be  given.  In  caries  there  is  also  no 
rotation  ;  and  pain  will  be  elicited  on  motion,  or  on 
gently  percussing  the  spine  or  tapping  the  head  or 
shoulders.      {See  also  Caries;  Art.  ix.,  vol.  ii) 

Treatment. — The  treatment  must  necessarily  vary 
according  to  the  severity  and  nature  of  the  deformity. 
When  there  is  evidence  of  general  and  muscular 
debility  the  general  health  and  muscular  tone  should 
be  improved  by  appropriate  remedies,  avoidance  of 
late  hours,  crowded  assemblies,  and  the  like.  The 
exciting  causes  of  the  deformity  must  be  sought  for, 
and,  if  possible,  removed.  Thus,  all  occupations 
necessitating  one-sided  positions,  bad  habits  of  sitting 


Scoliosis. 


333 


or  standing,  carrying  heavy  weights,  etc.,  should  be 
avoided  or  given  up.  When  there  is  fiat  foot  or  knock 
knee  these  should  be  remedied  ;  where  one  leg  is  shorter 
than  the  other,  a  boot  ^vith  a  high  sole  must  be  worn. 
These  means,  when  combined  with  a  judicious  selection 


Fig.  71.— Exercises  for  Lateral  Curvature. 


of  muscular  exercises  and  partial  recumbency,  will 
generally  be  sufficient  in  slight  cases  to  cure  or  greatly 
lessen  the  curvature.  In  severer  cases  the  degree  of 
improvement  will  be  proportionate  to  the  amount  of 
osseous  deformity  ;  whilst  where  there  is  much  rigidity 
and  confirmed  structural  change  little  or  no  improve- 
ment must  be  expected,  and  it  will  generally  be  found 
necessary,  at  least  in  hospital  patients,  to  employ,  in 


334  Manual  of  Surgery. 

addition  to  exercises,  some  form  of  meclianical  suppoH 
to  prevent  the  curves  from  getting  worse,  to  relieve  pain 
when  present,  and  to  improve  the  outward  appearance. 
The  exercises  should  be  directed  both  to  strengthening 
the  spinal  muscles  generally,  and  those  in  particular 
which  tend  to  correct  the  curves.  Amongst  the  former 
may  be  mentioned  swinging  by  the  hands  from  a  bar, 
forcibly  stretching  an  indiarubber  cord  attached  to  the 
floor,  the  use  of  dumb-bells,  chest  expanders,'  the 
extension  motions  of  drilling,  etc.  An  excellent 
exercise,  which  of  late  has  been  advocated  by  Dr. 
Busch  in  Germany,  and  Mr.  Roth  in  this  country, 
is  to  bring  the  patient's  body  over  the  end  of 
a  couch  or  table,  and  then,  whilst  he  is  prevented  from 
falling  by  an  assistant  holding  the  legs,  he  is  instructed 
to  alternately  flex  and  extend  the  body  at  the  hip, 
whilst  the  surgeon  resists  his  efibrts  (Fig.  71).  For 
strengthening  those  muscles  in  particular  that  tend  to 
straighten  the  curve,  the  back  should  be  manipulated 
till  that  posture  is  found  in  which  the  curves  are  the 
least  marked.  In  this  position  the  patient  can  only 
hold  himself  by  muscular  action,  and  at  first  for  only 
short  periods  at  a  time.  By  frequently  practising 
this  posture  the  muscles  thus  brought  into  play  are 
gradually  strengthened,  till  at  last  the  improved 
position  is  maintained  without  effort.  For  further 
strengthening  these  muscles,  Mr.  Both  advises  that  the 
patient  should  exercise  whilst  in  this  improved 
position,  especially  advocating  the  movements  above 
described.  Dr.  Busch,  for  tliis  purpose,  recommends 
that  whilst  the  patient  is  thus  supported  over  the 
end  of  the  table  the  surgeon  should  make  forcible 
pressure  with  his  hand  alternately  in  the  dorsal  and 
lumbar  cur\  e,  at  the  same  time  bending  the  body  to 
the  right  and  left  respectively. 

Another  device,    especially    indicated    in   lumbar 
curvature,  is  to  place  the  patient,  as  recommended  by 


Scoliosis. 


335 


M.    Bouvier  and  later  by  Mr.    Barwell,   on    a   scat 

raised  several  inclies  on  the  side  corres})onding  to  the 

convexity  of  the  lumbar  curve  ;  the  tilting  of  the  pelvis 

thus  produced,  when  the  patient  holds  himself  upright, 

counteracts  the  curves  by  its  tendency  to  ])roduce  others 

in  the    opposite    direction.     A  similar   effect  may  be 

obtained    by    placing    a    high   sole    on    the  boot,  and 

during  riding  by  sitting  on  the  off  side  of  the  saddle. 

None  of  these   exercises  should  be 

carried  to  the  extent  of  exhaustion, 

and  rest  on  the  back  for  half  an  hour 

to  an  hour   should  be   taken    after 

them.     The  back  should  be  further 

supported  by  the  use  of  a  reclining 

chair,  a  good   substitute  for  which 

may  be  made  by  raising  the  front 

legs   of  an   ordinary  chair    on    two 

bricks.     Where  there  is  much  stooj)- 

ing  my   elastic   brace  (see  Fig.  72) 

will    be    found    useful,    but    should 

only  be  worn    a   few  hours  a  day. 

At   night  time   the    patient  should 

sleep  on  the  side  opposite  to  the  dorsal  curve  ;  or  on 

a  Wolffs  suspensory  cradle. 

In  the  advanced  cases,  where  a  spinal  support  is 
thought  necessary,  a  poro-plastic  felt  jacket  or  plaster 
of  Paris  case  applied  during  suspension  may  be  used  ; 
or,  if  a  steel  instrument  is  preferred,  that  known  as 
Baker's  stays,  Chance's  support,  or  one  of  the  many 
other  forms  without  arm  crutches  may  be  adopted. 

AiNTEIlO-rOSTERIOR    CURVATUKE    OF    THE    SpINE. 

This  term  is  generally  restricted  to  those  cases  in 
which  the  spine  is  bent  either  in  a  backward  or  for- 
ward direction,  as  a  result  of  unequal  compression  of 
the  intervertebral  cartilages.  The  antero-posterior 
curvature  of  the  spine  depending  uj^on  disease  either 


Fii,'.  72. — Walsliani's 
Solid  Rubber  Shoul- 
der Brace. 


33^  Manual  of  Surgery. 

of  the  cartilages  or  of  the  vertebrae  is  known  as 
angular  curvature,  and  is  described  under  that  head 
in  the  Article  on  Diseases  of  tlie  Spine.  When  the 
curvature  is  convex  forwards  it  is  called  lordosis ; 
when  convex  backwards,  kyphosis. 

liOrdosis. — Iiiciirvatioii,  or  a  curving  of  the 
spine  with  the  convexity  forwards,  should  be  regarded 
as  a  symptom  rather  than  an  actual  disease.  In  the 
lumbar  region,  in  which  it  is  most  common,  and  in  the 
cervical  region,  it  is  merely  an  increase  of  the  normal 
curve ;  in  the  dorsal  region  it  is  a  reversal  of  it.  In 
the  lumhar  region  it  sometimes  appears  to  be  here- 
ditary ;  generally,  however,  it  is  there  formed  as  a  com- 
pensating curve  to  restore  the  equilibrium  of  the  body 
when  this  is  disturbed  by  the  tilting  forward  of  the 
pelvis,  as  in  congenital  dislocation  of  the  hip,  hip 
disease,  rickets,  etc.  Or  it  may  be  formed  as  a  com- 
pensating curve  in  caries  with  angular  curvature  in 
the  dorsal  region  ;  or  it  may  depend  upon  contrac- 
tion of  the  psoas  muscle,  consequent  upon  inflamma- 
tion or  abscess  in  its  substance.  In  the  cervical  region 
it  is  generally  compensatory  to  occipito-atloid  or  atlo- 
axoid  disease.  In  the  dorsal  region  it  is  very  rare, 
but  occasionally  occurs  as  a  compensating  curve  to 
caries  of  the  lower  cervical,  lower  dorsal,  or  lumbar 
vertebrae,  and  sometimes  in  double  lateral  curvature. 
The  treatment  should  rather  be  directed  to  the  cure  of 
the  occasionmg  cause  than  to  the  removal  of  the 
lordosis,  which  in  itself  is  not  usually  of  a  permanent 
nature. 

liypliosis.— Exciii'vatioii,  or  posterior  curva- 
ture, is  a  general  curving  of  the  spine  with  the  convexity 
backwards,  or  an  exaggerated  condition  of  the  normal 
dorsal  curve  depending  upon  unequal  compression 
of  the  intervertebral  cartilages.  It  is  often  seen  in 
infants  and  in  delicate  and  rickety  children  who  have 
been  allowed  to  sit  up    too    early    or    for    too    long 


KypHosis,  3117 

perio;ls.  In  growing  girls  and  lads  it  is  brought  on 
by  slouching  habits,  and  in  older  persons  may  be 
acquired  by  occupations  necessitating  stooping  ; 
hence  its  frequency  in  watchmakers,  clerks,  agricul- 
tural labourers,  etc.  It  may  also  be  induced  by  chronic 
bronchitis  and  chronic  rheumatism.  Sometimes  it 
would  appear  to  be  hereditaiy.  In  infants  the  kyphotic 
curve  is  most  marked  in  the  lower  dorsal  reijion, 
where  several  of  the  spinous  processes  often  appear  pre- 
ternaturally  prominent.  In  boys  and  giils  and  in  old 
people  the  curve  chiefly  aflects  the  upper  dorsal  region, 
producing  the  round  shoulders  with  which  all  are 
familiar.  The  point  of  chief  interest  is  to  distinguish 
between  the  comparatively  harmless  kyphotic  curve 
and  angular  curvature  depending  upon  caries  of  the 
vertebrae.  In  children  and  adults  it  is  usually  easy, 
but  in  rickety  infants  the  surgeon  is  unable  to  apply 
the  usual  tests  for  caries,  such  as  the  behaviour  of  the 
spine  in  stooping  or  rising  from  the  recumbent  position 
in  walking,  jumping,  etc.;  and  he  is,  moreover,  liable  to 
be  misled  by  the  acute  tenderness  and  evident  pain  on 
handling  that  often  occurs  in  rickets.  If  the  infant  is 
placed  horizontally  with  its  face  downwards  across  the 
nurse's  knees,  and  gently  extended  by  the  arms  and 
legs,  the  rickety  curve  disappears  or  may  become  ])os- 
teriorly  concave,  whilst  the  back  may  be  more  flexible 
than  natural  in  its  whole  extent.  In  caries,  on  the  other 
hand,  the  curvature  remains,  or  is  even  increased,  and 
the  spine  is  rigid  ;  the  infant  is,  moreover,  evidently 
uneasy  in  this  position,  and  tries  to  resist  the  exten- 
sion of  the  back  by  muscular  action  and  drawing  up 
of  the  legs.  Other  indications  of  rickets  will  also 
probably  be  present. 

Treatment. — In     the    infant    perfect    recumbency 

should  be  enjoined,  and    such    dietetic  and   hygienic 

measures  taken  as  to  restore  the  muscular  tone,  with 

appropriate  remedies  when  there  is  evidence  of  rickets. 

w— 21 


338  Manual  of  Surgery. 

Local  support  to  the  back  in  the  form  of  a  moulded 
leather  or  poro-plastic  jacket  is  recommended  by  high 
authorities.  But  I  prefer  trusting,  as  a  rule,  to 
recumbency.  In  growing  lads  and  girls  slouching 
habits  should  be  corrected,  and  a  system  of  muscular 
exercises  instituted,  combined,  when  there  is  debility, 
with  periods  of  recumbency  and  attention  to  the  gene- 
ral health,  A  sjjinal  brace  should  also  be  worn  for  a 
few  hours  daily.  In  the  confirmed  kyphotic  curve 
of  old  age  treatment  is  of  little  avail. 

Club  Hand. 

Several  rare  deformities  of  the  hand,  depending 
upon  a  contracted  condition  of  the  muscles  or 
malformation  or  absence  of  some  of  the  bones  of 
the  fore-arm  and  hand,  have  been  included  under 
this  term,  on  the  supposition  that  they  were 
analogous  to  club  foot.  The  most  common  of  these  de- 
formities, perhaps,  is  that  in  which  the  radius  and  one 
or  more  of  the  bones  of  the  carpus  and  the  thumb  are 
ubsent,  the  hand  being  fixed  in  the  position  of  flexion 
and  abduction.  Space  will  not  permit  of  a  further 
account  of  these  conditions,  nor  is  this  much  to  be  re- 
gretted as  they  can  have  little  or  no  interest  for  the 
practical  surgeon. 

Talipes  or  Club  Foot. 

irive  principal  forms  of  club  foot  are  described, 
talipes  equinus,  calccineus,  varus,  valgus,  and  cavus. 
These  forms  of  club  foot  may  be  variously  combined, 
and  are  then  spoken  of  as  equino- varus,  equino- valgus, 
calcaneo-valgus,  etc. 

Causes* — Club  foot  may  be  congenital  or  acquired. 
"Various  theories  have  been  advanced  to  account  for 
the  congenital  form.  The  chief  of  these  are  :  (1)  That 
it  is  due  to  a  spastic  muscular  contraction  consequent 


Talipes.  339 

upon  some  lesion  of  the  nervous  system,  the  bones 
being  drawn  into  their  abnormal  position  by  the  con- 
traction of  the  muscles,  and  there  fixed  by  adaptive 
shortening  of  the  muscles  and  ligaments.  No  alteration, 
however,  has  as  yet  been  discovered,  either  in  the  brain 
or  spinal  cord,  to  account  for  this  so-called  spastic 
contraction.  (2)  That  it  is  due  to  malposition  of  the 
foetus  in  utero,  the  bones  being  merely  maintained  in 
their  faulty  position  by  the  adaptive  shortening  of  the 
muscles  and  ligaments,  and  not  dra^Ti  there  by  any 
active  contraction  of  the  muscles.  (3)  That  it  is  due 
to  a  structural  alteration  in  the  form  of  the  bones  them- 
selves. An  alteration  in  the  shape  of  tJie  astragalus 
in  congenital  varus  no  doubt  exists,  but  it  appears  as 
likely  to  be  the  result  of  the  malformation  as  the  cause 
of  it.  The  congenital  form,  moreover,  may  occur  in 
several  members  of  the  same  family,  and  often  appears 
to  be  hereditary. 

The  causes  of  acquired  club  foot  are  numerous. 
Of  these,  infantile  paralysis  is  one  of  the  most  common, 
the  deformity  being  then  in  part  due  to  the  drawing  of 
the  bones  into  the  faulty  position  by  the  contraction 
of  the  muscles  antagonistic  to  those  paralysed,  and  in 
part  to  the  superincumbent  weight  of  the  body  tending 
more  and  more  to  increase  the  faulty  position.  The 
less  common  causes  will  be  referred  to  under  the  heads 
of  the  different  varieties. 

The  symptoms  of  club  foot  can  better  be  discussed 
under  each  variety. 

A  few  general  remarks  here  on  treatuieiit,  ho-v^- 
ever,  will  prevent  repetition  when  describing  that 
appropriate  to  each.  The  general  indications  are,  first 
to  restore  the  deformed  foot  to  the  natural  position, 
and  then  to  retain  it  there  until  it  shows  no  tendency 
to  relapse  and  the  functions  of  the  joints  and  muscles 
have  been,  as  far  as  possible,  regained.  For  the  first 
indication  both  operative  and  mechanical  treatment 


34©  Manual  of  Surgery, 

may  be  necessary  ;  for  the  second,  mechanical  siipporta 
and  physiological  after-treatment  should  be  employed. 

The  oj^erative  treatment  will,  in  by  far  the  greater 
number  of  cases,  be  merely  a  subcutaneous  division  of 
certain  tendons ;  but  in  inveterate  cases,  where 
tenotomy  and  all  other  means  have  failed,  some  form  of 
osteotomy  of  the  tarsus  becomes  necessary. 

Tenotomy  is  indicated  where  there  is  much 
rigidity,  and  the  foot  cannot  be  restored  by  manii^ula- 
tion  to  its  natural  position.  Its  object  is  to  perma- 
nently lengthen  the  contracted  tendon  by  the  insertion 
of  a  piece  of  new  material.  This  new  material  is 
formed  from  a  small  cell  exudation,  which,  when  the 
tendon  is  divided,  is  poured  out  from  the  divided  ends, 
and  is  ultimately  converted  into  fibrous  tissue  which  can- 
not be  distinguished  by  the  naked  eye  from  the  rest  of 
the  tendon.  Thus,  from  a  quarter  of  an  inch  to  an 
inch  and  a  half,  or  even  more,  of  new  tendon  may 
be  produced  according  to  the  rapidity  of  the  rate  of 
extension  afterwards  employed.  The  tendon  having 
been  made  tense  by  an  assistant,  the  tenotome  should 
be  passed  beneath  it  with  its  blade  parallel  to  it.  The 
tendon  should  now  be  relaxed  whilst  the  edge  of  the 
tenotome  is  turned  towards  it,  and  then  again  made 
tense  to  facilitate  its  division,  which  is  effected  by  cut- 
ting outwards  towards  the  skin.  The  assistant  should 
relax,  the  surgeon  cease  to  cut,  the  moment  the  resist- 
ance of  the  tendon  is  felt  to  be  overcome,  so  as  not  to 
pierce  the  skin  and  render  the  puncture  an  open  wound. 
On  removing  the  tenotome  a  dossil  of  oiled  lint  should 
be  placed  over  the  puncture  and  secured  by  a  piece  of 
strapping  and  a  bandage,  care  being  taken  to  prevent 
the  entrance  of  air  lest  suppuration  should  ensue,  and 
the  tendon  adhere  to  its  sheath  or  fail  to  unite.  It  is  usual 
to  place  the  part  in  the  deformed  position  on  a  splint  or 
in  some  form  of  Scarpa's  shoe,  till  the  puncture  has 
healed,  before  beginning  mechanical  extension.    Many, 


Talipes^  341 

however,  place  the  foot  at  once  in  its  natural  position 
in  plaster  of  Paris ;  but  in  so  doing  a  risk  is  i-un  of 
the  tendon  not  uniting,  or  of  the  uniting  tissue  remain- 
ing weak.  Whilst  using  plaster  of  Paris,  I  place 
the  foot  in  a  slightly  improved  position  only,  so  that 
the  ends  of  the  tendon  are  not  sufficiently  separated 
to  endanger  their  union. 

Tarsotomy. — Various  operations  having  for  their 
object  the  removal  of  certain  bones  or  portions  of  bones 
from  the  tarsus,  so  as  at  once  to  restore  the  normal 
shape  of  the  foot,  have  from  time  to  time  been  practised. 
Of  these  may  be  mentioned  Davy's  operation,  or  the 
removal  of  a  wedge-shaped  piece  of  bone  from  the 
tarsus,  and  Lund's  operation  of  excision  of  the  astra- 
galus. These  operations  have  been  followed  yA\h 
excellent  results,  but  it  cannot  be  too  strongly  urged 
that  they  should  only  be  undertaken  in  inveterate 
cases,  and  not  until  all  milder  measures  have  failed. 

Mechanical  treatment  aims  at  brincnns  the 
foot  slowly  into  its  natural  position  by  overcoming  the 
resistance  of  the  contracted  muscles  and  ligaments ;  or, 
where  tenotomy  has  been  previously  done,  by  so  regu- 
lating the  amount  of  new  tendon  formed  that  the  same 
result  is  obtained.  The  apparatus,  perhaps,  in  most 
general  use  is  some  kind  of  Scarpa's  shoe.  This,  in 
its  simplest  form,  consists  of  a  leather  slipper,  united 
to  a  leg  iron  and  calf  piece,  and  provided,  opposite  the 
ankle,  with  a  joint  which  can  be  moved  in  the  direc- 
tion of  flexion  and  extension  by  a  cog-wheel,  so  that  it 
can  be  made  to  correspond  to  the  shape  of  the  deformed 
foot.  In  this  position  it  is  strapped  on,  and  then  by 
a  daily  turn  of  the  cog-wheel  the  foot  is  gradually 
brought  into  its  natural  position.  But  as  equally  good, 
if  not  better,  results  may  be  obtained  by  plaster  of 
Paris,  which,  moreover,  is  much  cheaper,  I  have 
of  late  treated  all  the  suitable  cases  in  the  Ortho- 
paedic Department  at  St  Bartholomew's  Hospital  in 


342  Manual  of  Surgery. 

this  way.  If  plaster  of  Paris  is  used,  it  should  be  ap- 
plied once  or  twice  a  week,  according  to  the  ligamen- 
tous resistance  and  the  amount  of  new  tendon  it  is 
wished  to  produce.  A  cotton  wool  bandage  should  on 
each  occasion  be  placed  under  the  plaster. 

The  mechanical  supj^orts  for  maintaining  the  foot 
in  the  improved  position  will  be  described  under  each 
form  of  talipes. 

Physiological  after-treatment  aims  at  restoring  the 
proper  movements  of  the  joints  and  the  functional 
activity  of  the  muscles.  It  consists  in  active  and  pas- 
sive exercises,  shampooing,  faradisation,  hot  and  cold 
bathings,  and  last,  but  not  least,  the  education  of  the 
child  in  the  proper  use  of  the  foot  in  its  restored 
position.  Of  course,  in  paralytic  cases,  where  the 
muscles  have  undergone  fatty  change,  the  same  good 
result  cannot  be  expected,  and  in  such  a  mechanical 
apparatus  may  have  to  be  worn  for  life. 

Talipes  Equinus. 

In  this  form  of  club  foot  the  heel  is  drawn 
up  by  the  tendo  Achillis,  and  the  anterior  part  of 
the  foot,  in  consequence,  depressed.  There  is 
neither  inversion  nor  eversion ;  when  such  occurs,  the 
deformity  is  spoken  of  as  equino-varus,  or  equino- 
valgus.  Like  other  forms  of  talipes,  equinus  may  be 
congenital  or  acquired.  The  congenital  form  is  ex- 
tremely rare ;  tlie  causes  of  the  acquired  may  be 
enumerated  as  :  (1)  Contraction  of  the  muscles  of  the 
calf,  due  to  (a)  infentile  paralysis  of  the  anterior 
muscles  ;  (h)  extension  of  the  foot  for  long  periods,  as 
from  the  weight  of  the  bed  clothes  where  the  limb  is 
confined  on  a  splint.  (2)  Disease  in  or  about  the 
ankle  joint.  (3)  Contraction  of  cicatrices  following 
burns  and  wounds. 

Moi'bi<l  siiia-toiiiy.— The  os  calcis  is  drawn  up  by 
the  tendo  Achillis,- and  the  astragalus  in  consequence 


Talipes  Equinus. 


343 


half  tilted  out  of  its  socket  and  fixed  in  the  natural 
position  of  extension.  The  weight  is  thus  transmitted 
through  the  heads  of  the  metatarsal  bones,  wliich,  with 
the  anterior  part  of  the  tarsus,  are  bent  backwards 
and  downwards  from  the  transverse 
tarsal  joint,  so  that  in  severe  cases 
they  are  nearly  vertical  in  direction, 
and  almost  in  a  line  with  the  bones 
of  the  leg  ;  and  are  fixed  in  this  posi- 
tion by  the  contraction  of  the  plantar 
fascia  and  ligaments  and  short  mus- 
cles of  the  sole.  The  whole  foot, 
therefore,  appears  extended  and  short- 
ened, and  the  sole  unnaturally  con- 
cave. The  muscles  of  the  calf  and 
sole,  and  in  some  cases  even  the  deep 
muscles  of  the  leg  are  shortened,  but 
not,  as  a  rule,  otherwise  altered  in 
structure.  The  muscles  on  the  anterior  aspect  of  the 
leg  are,  in  paralytic  cases,  in  various  stages  of  fatty 
degeneration.  The  patient  walks 
upon  the  balls  of  his  toes,  and  with 
more  or  less  fatigue  and  lameness  ; 
whilst  if  both  feet  are  affected,  he 
may  be  unable  to  walk  at  all  or  even 
to  stand.  In  slight  cases  there  may 
l)e  no  obvious  deformity,  except  per- 
haps some  increase  in  the  concavity 
of  the  sole,  but  merely  an  inability 
to    flex    the    foot   beyond   the  right 


Fig.  73.  -  Talipea 
Equinus  from  pa- 
ralysis of  the  an- 
terior muscles. 


Fig.     7t.  —  Talipes 
Equiiio-varus. 


anffle.       In    such    cases,    which    are 


sometimes  spoken  of  as  right-ancjled 
contraction  of  the  tenclo  AchiUis,  there 
is  always  lameness,  on  account  of  the  limited  extension 
at  the  ankle  joint.  It  is  easily  detected  by  pressing 
the  knee  well  back  while  the  leg  is  extended.  In 
paralytic  cases,  in  consequence  of  want  of  power  in  the 


344  Manual  of  Surgery. 

anterior  muscles,  thetoesbecome  flexed  and  carried  back- 
wards towards  the  sole  at  their  metatarso -phalangeal 
joints  (Fig.  73),  instead  of  being  extended  as  in  ordi- 
nary equinus,  or  extended  at  these  joints  and  flexed  at 
their  first  interphalangeal  joints,  as  they  are  in 
spasmodic  cases.  In  extreme  paralysis  the  whole  foot 
may  be  carried  backwards,  so  that  the  dorsum  is 
placed  upon  the  ground  if  the  patient  attempts  to 
stand  or  walk.  In  such  cases  there  is  usually  shorten- 
ing of  the  limb  and  much  wasting,  whilst  the  skin  is 
blue  and  cold.  In  old-standing  cases  much  crippling 
is  often  present  from  the  formation  of  corns  over  the 
metatarsal  bones,  whilst,  as  the  result  of  the  contraction 
beinfj  ajreater  on  the  inner  than  on  the  outer  side  of 
the  sole,  an  inward  twist  is  given  to  the  foot  (equmo- 
varus)  (Fig.  74). 

TrcatMBent. — Tenotomy  of  the  tendo  Achillis  is 
usually  all  that  is  required.  But  where  there  is  much 
contraction  of  the  sole  the  plantar  fascia  or  any  tense 
bands  that  may  be  felt  should  first  be  divided,  and  the 
foot  placed  with  the  sole  straightened  out  as  much  as 
possible  in  plaster  of  Paris  or  in  a  Scarpa's  shoe  with  a 
jointed  sole-plate,  by  which  means  the  anterior  part  of 
the  foot  can  be  lifted  up.  In  a  week  or  fortnight, 
or  as  soon  as  the  sole  is  straight,  the  tendo  Achillis, 
which  has  thus  served  to  fix  the  os  calcis  while  the 
contracted  sole  was  being  straightened  out,  may  then 
be  divided.  The  heel  should  now  be  gradually  brought 
down  by  plaster  of  Paris,  or  an  Adams',  or  some  other 
form  of  Scarj^a's  shoe  till  the  foot  forms  the  same  angle 
with  the  lc2f  as  on  the  unaffected  side.  The  time 
required  for  this  varies  from  a  fortnight  in  the  infant 
to  six  weeks  in  a  paralytic  case.  If  any  varus  co- 
exists, it  should,  like  the  contraction  of  the  sole,  be 
cured  before  attacking  the  equinus.  To  prevent  a 
relapse,  a  boot  with  double  leg  irons  and  free  joint  at 
the  ankle    sliould   subsequently  be    worn    during   the 


Talipes  Varus.  345 

day,  and  a  rectangular  tin  si)liut  or  a  light  Scarpa's 
shoe  at  night,  or  traction  may  be  made  upon  the  foot 
by  means  of  an  indiarubber  band  properly  secured  to 
the  foot  and  calf.  But,  above  all,  physiological  means 
should  be  persevered  in  {see  page  342)  till  free  movement 
of  the  ankle  joint  has  been  obtained,  and  the  function 
of  the  atrophied  muscles  as  much  as  possible  restored. 
In  paralytic  cases  the  irons  should  have  a  stop-joint  at 
the  ankle,  with  a  toe-raising  spring  to  take  the  place 
of  the  paralysed  muscles,  and  where  the  limb  is  much 
shortened  the  boot  should  have  a  correspondingly  high 
sole.  The  irons,  where  the  muscles  of  the  thigh  are 
also  affected,  should  be  carried  above  the  knee,  and  the 
outer  iron  above  the  hip  to  the  pelvis,  where  it  is 
secured  to  a  pelvic  band.  There  should  be  a  free 
joint  at  the  hip,  and  a  ring  or  flute-key  catch  at  the 
knee  in  order  to  fix  the  knee  during  progression,  and 
to  allow  it  to  be  flexed  on  sitting  down,  or  going  up  or 
down  stairs. 

Talipes  Varus 

is  the  most  complicated  form  of  club  foot.  By 
some  it  is  sjjoken  of  as  equino- varus,  as  there  is 
undoubted  drawing  up  of  the  heel  as  well  as  in- 
version of  the  foot.  I,  however,  prefer,  with  ]Mr. 
Adams,  to  apply  the  simple  term  varus  to  the  de- 
formity under  consideration,  and  to  restrict  the  term 
equino- varus  to  those  cases  of  true  equinus  in  which 
there  is  a  slight  inward  twist  of  the  foot.  Talipes 
varus,  as  thus  understood,  occurs  most  frequently 
as  a  congenital  affection,  and  as  such  is  by  far  the 
most  common  form  of  congenital  club  foot.  It  usually 
affects  both  feet,  but  it  may  be  limited  to  one,  or 
there  may  be  varus  of  one  foot  and  valgus  of  the 
other.  It  is  often  complicated  by  weakness  of  the 
knee  joints,  occasionally  by  rigidity  of  the  knees  or 
hips,  and  more  rarely  by  other  congenital  abnormalities. 


346 


Manual  of  Surgery. 


as  deficiency  in  the   length  of    the   leg,   spina  bifida, 
clul)  hand,  etc. 

Morbid  anatomy.  {See  Fig.  75. ) — The  distortion 
may  briefly  be  said  to  consist  in  extension  of  the  foot  at 
the  ankle,  and  in  the  inversion  and  rotation  of  that  part 
of  the  tarsus  which  is  situated  in  front  of  the  trans- 
verse tarsal  joint.  The  length  assigned  to  this  article 
does  not  admit  of  a  detailed  account  of  the  distortion. 
It  must,  therefore,  suthce   to  say  that   the   os  calcis 

appears  drawn  u[) wards  by  the 
tendo  Achillis,  and  the  astra- 
galus partially  tilted  out  of  the 
ankle  joint,  whilst  the  scaphoid 
and  remaining  bones  of  the 
tarsus  appear  drawn  upwards 
and  inwards  by  the  tibialis 
anticus  and  posticus,  so  that 
the  scaphoid  is  placed  internal 


Figr.  75.  —  Talipes  Vanis, 
rrom  a  sijccimeu  iu  St. 
Bartholomew's  Hospital 
Museum. 


to  the  astragalus  instead  of  in 
front  of  it,  and  its  tuberosity  in 
close  contact  with  the  internal 
malleolus.  The  ligaments  on  the 


inner  side  of  the  foot  are  shoi-t- 
ened,  those  on  the  outer  side 
elongated.  The  muscles,  except  in  paralytic  cases,  in  which 
they  are  found  in^■arious  stages  of  fatty  degeneration,  are 
shortened,  but  otherwise  healthy.  The  tendon  of  the 
tibialis  anticus  lies  over  the  internal  malleolus,  instead 
of  in  front  of  it,  whilst  the  tibialis  posticus  is  displaced 
forwards,  so  that  it  lies  midway  between  the  anterior 
and  posterior  border  of  the  leg,  and  on  leaving  the 
malleolus  passes  straight  downwards  to  the  scaphoid 
instead  of  pursuing  its  normal  course.  The  altered 
relation  of  the  other  tendons  is  of  less  importance. 
In  congenital  cases  the  neck  of  the  astragalus  inclines 
more  inwards  than  natural,  so  that  the  head  looks 
forwards  and  inwards  instead  of  forwards. 


Talipes  Varus.  347 

Symptoms. — In  the  congenital  form  in  the  infant, 
the  anterior  part  of  the  foot  is  inverted,  whilst  the 
inner  border  is  turned  upwards,  and  the  outer  border 
downwards,  so  that  the  sole  looks  backwards  and 
the  dorsum  forwards.  In  severe  cases  the  inner 
border  may  be  drawn  into  contact  with  the  leg.  The 
long  axis  of  the  foot  is  shortened  and  bent  upon  itself, 
so  that  the  sole  is  unnaturally  concave  and  the  plantar 
fascia  tense.  The  internal  malleolus  is  obscured  by  the 
scaphoid,  and  the  heel  is  dra^wn  up,  and  is  small  and  ill 
formed.  In  slisfht  cases  the  foot  can 
be  turned  into  the  natural  position 
by  the  hand,  but  resumes  its  faulty 
shape  when  released.  If  the  foot 
has  been  walked  on  the  deformity 
is  still  further  increased  (Fig. 
76).  The  sole  then  looks  upwards 
as    well    as    backwards,    and    the     ^.      ^g  _  Talipes 

dorsum       downwards       as      well      as  Varus  ia  the  Adult. 

forwards,  whilst  the  transverse 
arch  is  narrowed  by  the  approximation  of  the 
fifth  metatarsal  bone  to  the  first.  The  bones, 
moreover,  become  rigidly  fixed  in  their  deformed 
position  by  the  adaptive  shortening  of  the  ligaments. 
In  consequence  of  the  narrowing  of  the  transverse 
arch  and  the  flexion  of  the  foot  at  the  transverse 
tarsal  joint,  a  longitudinal  and  an  oblique  furrow 
are  formed  in  the  sole,  and  are  considered  by  ]Mr. 
Adams  as  diagnostic  of  the  congenital  form.  Along  the 
outer  border  and  on  the  dorsum  of  the  foot  the  skin 
becomes  thickened,  whilst  a  bursa  often  forms  beneath 
it,  and  is  liable  to  become  inflamed  or  to  suppurate 
and  leave  an  intractable  ulcer.  The  acquired  form, 
which  is  usually  due  to  infantile  paralysis,  may  gene- 
rally be  distinguished  from  the  congenital  by  the 
history  of  tlie  case,  by  the  wasting,  shortening,  and 
coldness  of  the  afliected  limb,  by  the  general  rounded 


348  Manual  of  Surgery, 

and  smooth  appearance  of  the  foot,  and  by  the  absence 
of  rigidity  and  of  the  fuiTOws  in  the  sole. 

Ti'eatnACUt. — In  very  slight  infantile  cases,  hold- 
ing the  foot  in  the  natural  position  for  certain  periods 
during  the  day,  and  in  slightly  severer  cases,  similar 
manipulations  combined  with  mechanical  extension, 
will  often  suffice.  But  where  there  is  much  rigidity, 
tenotomy  is  generally  necessary.  This  is  best  done 
when  the  child  is  about  two  months  old,  although  for 
hospital  patients,  where  the  physiological  after-treat- 
ment is  apt  to  be  neglected,  it  had  better  be  delayed 
until  the  child  is  about  ten  months  old,  that  is,  till  just 
before  it  is  able  to  walk.  In  a  severe  case,  the  tibialis 
anticus  and  posticus,  the  tendo  Achillis,  and  the  plantar 
fascia,  require  division.  Of  these,  the  tibialis  anticus 
and  posticus  should  be  divided  first,  lea^dng  the  tendo 
Achillis  to  act  as  a  point  d'appui,  whilst  the  inversion 
of  the  foot  is  being  overcome  by  mechanical  means ; 
and  subsequently,  at  the  end  of  a  fortnight  or  three 
weeks,  or  as  soon  as  the  foot  has  been  brought  into  a 
straight  line  with  the  leg,  the  tendo  Achillis  should  be 
divided  and  the  heel  brought  down.  Where  there  is  much 
contraction  of  the  sole,  the  plantar  fascia,  or  practically 
any  tense  bands  that  can  be  felt,  should  be  divided 
after  the  tibials,  but  before  the  tendo  Achillis.  In 
some  cases  the  inversion  of  the  foot  (the  varus  posi- 
tion) may  be  overcome  by  mechanical  treatment  alone, 
although  the  heel  cannot  thus  be  brouijht  down.  In 
such,  the  division  of  the  tendo  Achillis  will  suffice. 
The  division  of  the  tendo  Achillis  and  plantar  bands 
has  already  been  discussed  under  equinus.  In  dealing 
with  the  tibials  the  anticus  should  be  divided  first, 
especially  where  it  is  much  contracted.  This  is  best 
done  above  the  anterior  annular  ligament,  the  teno- 
tome being  passed  close  to  the  fibular  side,  so  as  to 
avoid  injuring  the  anterior  tibial  artery.  The  tibialis 
posticus   should    be   divided  just  above  the  internal 


Talipes  Varus,  349 

annular  ligament.  In  the  adult  the  postenor  border 
of  the  tibia  serves  as  a  guide  to  it,  but  in  a  fat  infant 
this  cannot  ahvays  be  felt,  and  the  puncture  should 
then  be  made  midway  between  the  anterior  and 
posterior  border  of  the  leg.  The  sheath  having  been 
opened  by  a  sharp-pointed  tenotome,  the  operation 
should  be  completed  with  a  blunt-pointed  one,  to  avoid 
pricking  the  posterior  tibial  artery.  After  the  division 
of  the  tibialis  posticus,  the  flexor  longus  digitorum 
may  be  severed,  if  desired,  by  passing  the  tenotome 
slightly  deeper ;  not  too  deeply,  however,  lest  the  pos- 
terior tibial  artery  be  wounded.  Should  this  accident 
happen,  which  may  be  known  by  a  slight  spurt  of 
blood  and  blanching  of  the  foot,  firm  pressure  must  be 
applied,  and  no  harm,  as  a  rule,  will  ensue.  After  the 
di\dsion  of  the  tibials  the  foot  may  either  be  placed  in 
a  slightly  improved  position  in  plaster  of  Paris,  or  on 
a  tin  varus  splint  in  the  deformed  position  for  two  or 
three  days,  until  the  punctures  have  healed.  It  may 
then  be  gradually  brought  into  the  straight  line  with 
the  leg,  either  by  reapplying  the  plaster  every  few 
days,  or  by  daily  bandaging  it  to  the  splint.  If  the 
latter  is  used,  it  should  be  placed  alternately  on  the 
inner  and  outer  side  of  the  leg  to  avoid  injurious  pres- 
sure, and  the  bandage  should  be  applied  from  above 
downwards,  so  as  first  to  fix  the  leg  and  then  to  draw 
the  foot  to  the  splint.  In  either  of  these  ways  the 
inversion  of  the  foot  will  generally  be  overcome  in  a 
fortnight  or  three  weeks,  and  the  tendo  Achillis  may 
then  be  divided  as  soon  as  the  foot  remains  in  a 
straight  line  w4th  the  leg  on  the  removal  of  the  plaster 
or  splint,  the  heel  being  brought  down  either  by 
plaster  of  Paris  or  by  a  Scarpa's  shoe,  as  described  in 
equinus.  Some  mechanical  apparatus  must  be  worn 
during  the  day,  for  at  least  twelve  months,  to  prevent 
a  relapse,  and  a  rectangular  tin  splint,  or  a  light 
Scarpa's  shoe  at  night,  especially  when  any  tendency 


350  Manual  of  Surgery. 

to  inversion  remains.  At  the  same  time  it  is  most 
important  that  the  fjhysiological  means  described  at 
page  342  should  be  persevered  in  till  the  movements 
of  the  foot  have  been  as  much  as  possible  regained. 
For  the  infant,  the  best  mechanical  apparatus  is  perhaps 
Mr.  Adams'  boot.  It  is  provided  with  an  outside  leg 
iron  and  calf  band,  with  a  free  joint  at  the  ankle  to 
allow  of  passive  movements  of  extension  and  flexion 
being  carried  on  during  its  use.  For  older  children 
and  adults,  a  boot  with  double  leg  irons,  free  joints 
at  the  ankle,  and  a  strap  passing  across  from  the 
outer  side  of  the  boot  over  the  inner  iron  is  requisite. 
Where  the  whole  leg  tends  to  twist  inwards  at  the 
knee  joint  from  relaxation  of  the  ligaments,  the  irons 
should  be  carried  above  the  knee  and  the  outer  iron 
above  the  hip  and  secured  to  a  pelvic  girdle.  In 
paralytic  cases  there  should  be  a  stop-joint  at  the  ankle, 
and  a  toe-raising  spring  to  counteract  the  tendency  of 
the  tendo  Achillis  to  re-contract.  When  the  muscles 
of  the  thigh  are  seriously  affected,  the  joints  at  the 
knee  must  be  fixed  to  permit  of  walking.  This  is  best 
done  by  the  ring  or  flute-key  catch,  which  permits  of 
the  irons  being  bent  when  the  patient  wishes  to  sit 
down. 

Relapsed  varus  is  unfortunately  too  common, 
and  this,  perhaps,  chiefly  because  the  proper  mechanical 
and  physiological  after-treatment  is  apt  to  be  neglected. 
The  incomplete  division  of  the  tendons,  their  division 
in  a  wrong  order,  the  inflammatory  adhesion  of  a 
tendon  to  its  sheath,  and  in  long-standing  cases  the 
shortening  of  the  ligaments  and  adaptive  growth  of 
the  bones  in  their  malposition,  all  render  a  relapse 
liable  to  occur.  The  treatment  of  such  cases  is 
generally  unsatisfactory.  The  mechanical  and  physio- 
logical means  above  described  should  first  be  tried. 
This  failing,  tenotomy  must  again  be  done,  and  as  a 
last  resource  some  form  of  tarsotomy.     {See  page  341.) 


Talipes  Calcaneus. 


351 


Talipes  Calcaneus 

niay  1)0  congenital  or  acquired ;  but  both  forms  are 
rare.  The  acquired  may  be  due  to  infantile  paralysis 
affecting  the  posterior  muscles,  non-union  or  too  great 
separation  of  the  ends  of  the  tendo  Acliillis  after  rup- 
ture or  division  for  talij)es  equinus,  or  contractions 
followinir  burns  or  wounds  on  the  front  of  the  log. 

Syniptoiiis. — In  congenital  cases  both  feet  are 
generally  affected ;  the  anterior  part  of  the  foot  is 
drawn  up,  often  a  little  everted,  and  generally  rigidly 
fixed  in  this  position  by  the  contraction  of  the  extensor 
tendons.  In  the  ac- 
quired cases  due  to 
infantile  paralysis  of 
the  calf  muscles  the 
heel  is  placed  first  to 
the  ground  in  walking  ; 
but  there  is  no  rigidity 
of  the  extensors,  so 
that  the  foot  is  not 
drawn  up  towards  the 

leg,  and  can  be  placed  by  the  surgeon  in  the  position 
of  equinus.  The  anterior  part  of  the  foot,  moreover, 
drops  downwards  from  the  transverse  tarsal  joint  {see 
Fig.  77),  and  the  tendo  Achillis,  instead  of  standing  out 
tensely,  runs  as  a  flattened  band  close  behind  the 
ankle. 

Treatment.  —  In  slight  congenital  cases  mani- 
pulation and  drawing  down  the  foot  will  often  sufiice  ; 
this  failing,  the  extensor  tendons  should  be  divided 
and  the  foot  rectified  by  plaster  of  Paris  or  a  Scarpa's 
shoe.  In  paralytic  cases,  a  boot  with  double  leg  irons, 
a  slop-joint  at  ankle,  and  toe-depressing  spring  should 
be  worn,  and  faradisation,  shampooing,  etc.,  of  the 
leg  sedulously  employed.  Where  any  portions  of 
the  calf  muscles,  as  shown  by  electrical  tests,  remain 


Fig.  77.— Talipes  Calcaneus.  The  foot 
before  and  after  section  of  the 
tendo  Achillis. 


352  Manual  of  Surgery. 

unaffected  by  the  paralysis,  they  may,  to  a  great  ex- 
tent, regain  their  function  by  bringing  them  into  use  by 
shortening  the  elongated  tendo  Achillis.  This  may  be 
done  by  removing  half  an  inch  or  so  of  the  tendon 
obliquely,  splicing  the  divided  ends,  and  retaining  the 
foot  in  the  equinus  position  in  plaster  of  Paris  till  firm 
union  is  obtained.  I  have  performed  this  operation  in 
some  half-a-dozen  cases,  and  have  seen  it  done  by  my 
colleague,  Mr.  Willett,  in  several  others,  with  con- 
siderable improvement  to  the  patient.  In  Fig.  77 
the  foot  is  represented  before  and  after  the  shortening 
of  the  tendon. 

Talipes  Valgus,  or  Flat  Foot, 

is  characterised  by  a  flattening  of  the  longitudinal 
and  transverse  arches  of  the  foot,  and  by  more 
or  less  eversion  of  its  anterior  part.  Though  rare 
as  a  congenital,  it  is  frequent  as  an  acquired 
deformity,  and  would  then  appear  to  depend 
upon  various  causes.  The  chief  of  these  are, 
perhaps,  the  yielding  of  the  ligaments  of  the  sole, 
and  the  relaxed  condition  of  the  muscles  which 
normally  support  the  plantar  arches,  in  consequence  of 
general  debility  and  want  of  muscular  tone,  combined 
with  long  standing,  carrying  heavy  weights,  etc. 
Hence  the  frequency  with  which  it  occurs  in  growing 
underfed  lads,  in  whom  it  is  frequently  associated 
with  knock-knee,  in  waiters,  housemaids,  policemen, 
etc.  Amongst  other  causes  must  be  mentioned  rheu- 
matism (especially  gonorrhoeal),  rickets,  sprains  or 
other  injuries  of  the  plantar  ligaments,  and  paralysis  of 
certain  muscles  of  the  leg. 

Morbid  auatomy. — The  plantar  fascia,  caloa- 
neo-scaphoid,  and,  to  a  lesser  extent,  the  other  ligaments 
of  the  sole,  are  elongated,  and  the  bones  on  the  inner 
side  of  the  foot,  instead  of  forming  an  arch,  are  de- 
pressed and  in  contact  with  the  ground.     At  the  same 


J^LAT  Foot. 


353 


time,  the  bones  in  front  of  the  transverse  tarsal  joint 
are  slightly  everted,  leaving  the  articular  surface  of 
the  head  of  the  astragalus  exposed,  and  forming  a  pro- 
minence on  the  inner  side  of  the  foot.  In  severe  cases, 
and  usually  in  the  congenital  variety,  tlie  tuljerosity  of 
the  OS  calcis  is  drawn  •u})wards  by  the  tendo  Achillis, 
whilst  the  outer  border  of  the  foot  is  raised  from  the 
ground,  and  the  whole  of  the  Ijones  in  front  of  tlie 
transverse  tarsal  joint  ai'e  drawn  uj)wards  towaids  the 
front  of  the  leg  by  the  nntei'ior  muscles,  rendering  the 
dorsum  of  the 
foot  concave  and 
the  sole  convex. 
Syniptoitis. 
— Pain  in  front 
of  the  instep,  or 
about  the  inser- 
tion of  the  tibial 
or  peroneal  ten- 
dons, and  often  of 
a  severe  and  crip- 
pling   character, 

is  generally  present,  and  is  always  worse  after  a  day's 
work.  The  foot  looks  broader  and  longer  than  natural 
(Fig.  78),  the  sole  flat,  its  inner  border  in  contact 
with  the  ground^  whilst  its  anterior  part  a])pears 
slightly  everted,  especially  in  walking.  The  instep  is 
low,  the  internal  malleolus  depressed,  w  hilst  two  pro- 
minences, formed  by  the  tuberosity  of  the  scaphoid 
and  the  partly  exposed  head  of  the  astragalus,  appear 
on  the  inner  side  of  the  foot.  In  slight  cases  the 
natural  symmetry  of  the  foot  is  restored  if  the  patient 
raises  himself  on  tip-toe,  or  stands  on  the  outer  edge 
of  the  foot ;  whilst  on  manipulation  there  is  no  rigidity, 
and  the  two  prominences  can  be  made  to  disai)pear  by 
gentle  pressure.  In  severer  cases  the  foot  is  ligidly 
fixed  in  its  deformed  condition,  and  the  peronei  stand 
X— 21 


Fit 


-Tfilipes  Vfilsriis,   or  Flat   Foot ; 
2ucl  (letrree. 


334  Manual  of  Surgery. 

addition  to  exercises,  some  form  of  mechanical  suppoK 
to  prevent  the  curves  from  getting  worse,  to  relieve  pain 
when  present,  and  to  improve  the  outward  appearance. 
The  exercises  should  be  directed  both  to  strengthening 
the  spinal  muscles  generally,  and  those  in  particular 
which  tend  to  correct  the  curves.  Amongst  the  former 
may  be  mentioned  swinging  by  the  hands  from  a  bar, 
forcibly  stretching  an  indiarubber  cord  attached  to  the 
floor,  the  use  of  dumb-bells,  chest  expanders,'  the 
extension  motions  of  drilling,  etc.  An  excellent 
exercise,  which  of  late  has  been  advocated  by  Dr. 
Busch  in  Germany,  and  Mr.  Roth  in  this  country, 
is  to  bring  the  patient's  body  over  the  end  of 
a  couch  or  table,  and  then,  whilst  he  is  prevented  from 
falling  by  an  assistant  holding  the  legs,  he  is  instructed 
to  alternately  flex  and  extend  the  body  at  the  hip, 
whilst  the  surgeon  resists  his  efforts  (Fig.  71).  For 
strengthening  those  muscles  in  particular  that  tend  to 
straighten  the  curve,  the  back  should  be  manipulated 
till  that  posture  is  found  in  which  the  curves  are  the 
least  marked.  In  this  position  the  patient  can  only 
hold  himself  by  muscular  action,  and  at  first  for  only 
short  periods  at  a  time.  By  frequently  practising 
this  posture  the  muscles  thus  brought  into  play  are 
gradually  strengthened,  till  at  last  the  improved 
position  is  maintained  without  effort.  For  further 
strengthening  these  muscles,  Mr.  Both  advises  that  the 
patient  should  exercise  whilst  in  this  improved 
position,  especially  advocating  the  movements  above 
described.  Dr.  Busch,  for  tliis  purpose,  recommends 
that  whilst  the  patient  is  thus  supported  over  the 
end  of  the  table  tlie  surgeon  should  make  forcible 
pressure  with  his  hand  alternately  in  the  dorsal  and 
lumbar  cur\e,  at  the  same  time  bending  the  body  to 
the  right  and  left  respectively. 

Another  device,    especially    indicated    in   lumbar 
curvature,  is  to  place  the  patient,  as  recommended  by 


Scoliosis.  335 

M.   Bouvier  and  later  by  Mr.    Bar^-ell,   on   a   seat 

raif;ed  seA'eral  inches  on  the  side  corresponding  to  the 

convexity  of  the  lumbar  curve  ;  the  tilting  of  the  pelvis 

thus  ]iroduced,  when  the  patient  holds  himself  upright, 

counteracts  the  curves  by  its  tendency  to  ]  iroduce  others 

in  the    opposite    direction.     A  similar   effect  may  be 

obtained    by    placing    a   high   sole    on    the  boot,  and 

durincr  lidinsf  by  sittins;  on  the  off  side  of  the  saddle. 

None  of  these   exercises  should  be 

carried  to  the  extent  of  exhaustion, 

and  rest  on  the  back  for  half  an  hour 

to  an  hour   should  be   taken    after 

them.     The  back  should  be  further 

supported  by  the  use  of  a  reclining 

chair,  a  good   substitute  for  which 

may  be  made  by  raising  the  front 

legs   of  an   ordinary   chair    on    two 

bricks.      Where  there  is  much  stooj)- 

ing  my    elastic    brace   {see  Fig.  72) 

will    be    found   useful,    but    should      l%-T'^-^''^tc''^'? 

'  ^  Solid  Eubber  Slioul- 

only  be  worn    a   lew  hours  a  day.      der  Brace. 

At   night  time  the    patient  should 

sleep  on  the  side  opposite  to  the  dorsal  curve  ;  or  on 

a  Wolffs  suspensory  cradle. 

In  the  advanced  cases,  where  a  spinal  support  is 
thought  necessary,  a  poro-plastic  felt  jacket  or  plaster 
of  Paris  case  applied  during  suspension  may  be  used  ; 
or,  if  a  steel  instrument  is  preferred,  that  knowm  as 
Baker's  stays,  Chance's  support,  or  one  of  the  many 
other  forms  without  arm  crutches  may  be  adopted. 

Anteroposterior  Curvature  of  the  Spine. 

Tliis  term  is  generally  restricted  to  those  cases  in 
which  the  spine  is  bent  either  in  a  backward  or  for- 
ward direction,  as  a  result  of  unequal  compression  of 
the  inter\ertebral  cartilages.  The  antero-posterior 
curvature  of  the  spine  depending  upon  disease  either 


356  MAh^UAi.  OF  Surgery. 

interossei,  hut  the  exact  pathology  is  hardly  hnown. 
Division  of  the  plantar  fascia  will  sometimes  suffice, 
but  where  the  tendo  A.chillis  is  contracted  it  must 
subsequently  be  divided  also.  At  times,  however, 
tenotomy  of  the  extensor,  or  even  of  the  flexor 
tendons  as  well,  may  be  necessary.  A  steel  sole  plate, 
with  slots  cut  at  the  extremity,  through  which  elastic 
straps  pass  to  press  down  the  toes,  should  be  worn  in 
the  boot  to  prevent  a  relapse. 

Knock-knee. 

Genu  valgum,  or  knock -knee,  is  a  deformity 
in  which,  when  the  knees  are  extended  and  placed 
together,  with  the  patellae  looking  directly  forwards, 
the  legs,  instead  of  being  parallel  to  each  other, 
diverge,  so  that  the  malleoli  cannot  be  brought  into 
contact.  One  or  both  knees  may  be  affected,  or  there 
may  be  genu  valgum  on  one  side  and  genu  varum  on 
the  other.  Flat  foot,  curvature  of  the  tibi?e  and 
femora,  and  lateral  curvature  of  the  spine,  are  not 
infrequent  concomitants. 

i'aiise. — The  affection  occurs  chiefly  at  two  periods 
of  life ;  in  children  between  the  second  and  the 
seventh  year,  and  in  growing  lads,  and  less  frequently 
girls,  between  the  fourteenth  and  the  eighteenth.  At 
the  former  period  it  is  generally  the  result  of  rickets, 
at  the  latter,  of  the  carrying  of  heavy  weights,  long 
standing,  and  the  like.  The  way  in  which  these 
causes  become  operative  has  long  been  a  source  of 
dispute.  Thus,  by  some  the  muscles,  by  others  the 
ligaments,  and  by  others  the  bones,  are  believed  to  be 
primarily  at  fault.  That  the  l)iccps  tendon  and 
external  lateral  ligament  are,  in  some  instances,  con- 
tracted and  tense,  that  in  others  the  internal  ligament  is 
elongated,  allowing  free  lateral  movement  of  the  joint, 
and  that  in  others  again  there  is  a'  marked  elongation 
of  the  internal  condyle  of  the  femur,  or  uprising  of 


Knock- KNEE.  3  5  7 

the  inner  tuberosity  of  tlie  tibia,  are  undoubted  facts, 
but  it  is  open  to  question  wliicli  is  the  primaiy  lesion 
and  which  the  secondary  phenomenon.  Jn  all  the 
rachitic  cases,  and  in  most  of  the  others  that  I  have 
seen,  tliere  has  been  an  evident  elongation  of  the 
internal  condyle,  and  in  some  of  these  a  contracted 
condition  of  the  biceps  tendon,  and  in  others  a  relaxed 
interaal  lateral  ligament ;  but  in  very  few  have  I 
found  a  relaxed  state  of  the  ligament  without  ob\ious 
overgrowth  of  the  bone.  I  am  therefore  inclined  to 
regard  the  osseous  as  commonly  the  primaiy  lesion, 
although  I  admit  that  in  those  i-apid  cases  in  which 
the  deformity  has  been  developed  in  a  few  months 
from  excessive  wei^jht  bearing,'  the  stretchini;  of  the 
ligament  may  be  the  primary  factor.  Concerning  the 
elongation  of  the  internal  condyle  and  uprismg  of 
the  inner  tuberosity  of  the  tibia,  it  would  appear 
probable  that  there  is  an  active  increase  of  growth  at 
the  inner  pai-t  of  the  epiphysial  line,  and  a  deficient 
growth  or  premature  synostosis  of  the  epiphysis  and 
diaphysis  at  the  outer  part,  both  being  probably 
induced  by  the  diminished  pressure  on  the  inner,  and 
increased  pressure  on  the  outer  condyle,  due,  in  the 
cases  of  rickets,  to  the  mere  weight  of  the  body  of  the 
child  in  walking,  and  in  older  patients  to  carrying 
heavy  weights,  etc. 

Symptoms. — The  deformity  is  usually  quite  evi- 
dent, although  in  slight  cases  it  may  be  somewhat 
disguised  by  the  patient  flexing  his  knees  in  walk- 
ing. Pain  or  a  sense  of  weakness  is  complained  of 
after  exercise  ;  or  the  patient  may  be  unable  to  walk, 
or  the  knees  may  cross  each  other  in  doing  so,  the 
malleoli  in  extreme  cases  being  as  much  as  a  foot 
or  more  apai-t.  On  extending  the  legs  with  the 
patellae  to  the  front,  the  tibije  are  found  to  diverge, 
but  on  flexing  the  legs  at  right  angles  to  the  thighs 
the  malleoli  can  be  made  to  touch.      This  has  been 


358  Manual  of  Surgery. 

explained  011  the  supposition  that,  whilst  the  in- 
ternal condyle  is  longer  than  the  external  below,  they 
are  on  the  same  level  posteriorly  ;  but  the  uiore  pro- 
bable explanation  would  ap})ear  to  lie  in  the  fact  that 
the  plane  of  tlie  joint  is  obliquely  placed. 

Ti'ciitiiieiit. — \\\  slight  cases  where  the  bones  are 
still  soft  the  deformity  may  be  cured  by  keeping  the 
child  entirely  off  its  legs  by  means  of  suitable  splints, 
combined  with  the  use  of  the  dietetic,  hygienic,  and 
medicinal  treatment  indicated  in  rickets.  Sliccht  cases 
also  in  older  subjects,  when  appearing  to  depend  on 
the  relaxed  state  of  the  internal  lateral  ligament, 
may  also  be  cured  by  the  long  use  of  instruments.  For 
such,  an  outside  leg-iron  stretching  from  a  pelvic 
girdle  above  and  attached  to  a  boot  below,  and  pro- 
vided with  a  knee  cap,  a  free  joint  at  the  hip  and 
ankle,  and  a  double  joint  at  the  knee  permitting  of 
flexion  and  extension,  and  of  lateral  movements  to 
correct  the  deformity,  should  be  worn  during  the  day. 
At  night  the  legs  shoidd  be  bandaged  together  with 
a  pad  between  the  knees,  or  a  night  instrument  worn 
consisting  of  a  trough  for  the  thigh  and  leg  with  a 
ratchet  joint  at  the  knee.  It  is  only  in  very  slight 
cases,  however,  that  instruments  are  of  any  service. 
By  their  use  the  legs  can,  no  doubt,  be  straightened, 
but  it  is  at  the  expense  of  stretching  the  external 
lateral  ligament,  and  consequently  rendering  the  kneo 
joint  so  ilail-like  that  the  patient  is  unable  to  walk, 
and  hardly  to  stand,  without  his  irons.  A  striking 
example  of  this  Avas  furnished  lately  by  a  case  under 
my  colleague,  Mr.  Willett.  The  lad  wore  an  instru- 
ment for  upwards  of  four  years.  At  the  end  of 
that  time,  when  the  irons  were  taken  off,  his  legs 
could  either  be  jJaccd  in  the  knock-kneed  or  straight 
position  j  in  the  latter  there  was  a  full  inch  between 
the  external  condyle  and  the  tibia.  He  was  there- 
fore placed  in  plaster  of  Paris  in  the  original  deformed 


Knock-knee.  359 

position  for  twelve  months  till  the  external  ligament 
had  again  consolidated.  INIacewen's  operation  was 
then  performed,  and  in  a  few  weeks  the  lad  could 
walk  without  instruments,  with  strong  and  useful 
knee  joints.  The  best  and  quickest  treatment,  except 
in  slight  cases,  would  appear  to  he  some  form  of 
subcutaneous  osteotomy  of  the  femur,  although  in 
France  forcible  straightening,  either  by  the  hands 
{Delore^s  rnetliod)  or  by  an  instrument  called  an  osteo- 
clast, is  the  opojative  procedure  which  has  perhaps 
met  with  most  favour.  The  scope  of  this  worlv 
does  not  permit  of  a  description  of  the  various  forms 
of  osteotomy  that  have  of  late  years  been  invented. 
A  short  account,  however,  of  those  known  as  Mac- 
ewen's,  Ogston's,  and  Reeves's  (the  operations  now 
commonly  practised)  will  be  given. 

Macewen's  opei'ation  consists  in  partially  dividing 
the  femur  just  above  the  epij^hysis  with  a  chisel, 
leaving  the  posterior  part  of  the  bone  which  is  in 
contact  with  the  popliteal  artery  intact,  and  then 
crackiug  tliis  across  by  forcibly  straightening  the 
limb.  It  is  the  operation  now  most  frequently  done, 
and  although  it  has  in  a  few  instances  been  attended 
with  serious  accidents,  such  as  a  wound  of  the  pop- 
liteal artery,  it  has  been  performed  many  hundreds  of 
times  with  the  best  results. 

Ogston's  operation  consists  in  sawing  obliquely, 
while  the  limb  is  in  the  extended  position,  through 
the  internal  condyle,  which,  thus  se[)arated,  slides 
upwards  on  to  the  diaphysis  when  the  leg  is  forced 
into  a  straight  position.  The  chief  objection  to 
it  is  that  the  knee  joint  is  opened,  and  that  it  Ls 
liable,  in  consequence,  to  be  followed  by  inflammation 
and  stiflness  of  the  joint,  and  even  by  suppuration 
and  anchylosis. 

lieevess  condylar  operation  is  a  modification  of 
Ogstou's.       The   condyle   is   loosened  with   a   chisel 


;6o 


Manual  of  Surgery. 


•1..: 


instead  of  a  saw.  The  object  aimed  at  is  to  in- 
troduce the  chisel  beliind  tlie  synovial  membrane, 
and  to  stop  short  of  the  articular  surface  so  as  to 
avoid  Oldening  the  joint.       Though   it  is  questionable 

whether  the  joint  is  not  as 
often  opened  as  not  by  this 
method,  the  chisel  af)pears  to 
do  less  damage  than  the  saw, 
and  the  operation  has  been 
followed  by  few,  if  any,  of 
those  complications  that  have 
attended  Ogston's. 

In  Reeves's  diajjhi/slal 
operation  the  shaft  of  the 
femur  is  partially  divided 
with  the  chisel  from  the 
outer  side  at  the  junction  of 
the  middle  with  the  lower 
third,  and  then  cracked 
across.  (The  line  of  these 
various  osteotomies  is  shown 
in  Fig.  81). 

Delore^s  operation  con- 
sists in  forcibly  straight- 
ening the  limb.  The  object 
aimed  at  is  the  tearing  of 
the  lower  epij^hysis  of  the 
femur  from  the  diaphysis, 
but  it  is  doubtful  whether 
other  injuries,  such  as  rupture 
of  the  external  lateral  liga- 
ments, etc.,  are  not  as  often  produced,  as  it  has  been 
followed  l>y  suppuration,  necrosis  of  the  femur,  and  other 
complications.  MM.  Kobin  and  Collin  have  invented 
instruments  for  making  Delore's  operation  more  pre- 
cise, which  then  goes  by  the  name  of  ostcoclasy. 
After  any   of   these  operations  the   limb   should  be 


Fig.Sl.— 1, Roevofe's  diapliysLil 
operation  ;  2,  Mace  wen's 
operation;  3,  O^stou's  ope- 
ration ;  \,  Eceves's  condy- 
lar operation. 


Bow- Legs.  361 

placed  in  a  btraiglit  position  on  a  long  splint  or  in 
Bavarian  plaster  splints  for  a  month,  and  subsequently 
for  another  six  weeks  in  ordinary  plaster  bandages, 
till  consolielation  has  occurred. 

Bow-Legs. 

ijieiiu  vartiiii,  or  bow-legs,  is  a  deformity  in 
which,  when  the  malleoli  are  placed  in  contact  with 
the  knees  fully  extended  and  the  patelhie  looking 
dii'ectly  forwards,  the  knees,  instead  of  being  in  contact, 
are  separated  from  each  other  by  a  variable  intervaL 
As  in  knock-knee,  both  legs,  or  one  leg  only,  may  be 
aliected,  or  there  may  be  genu  varum  on  one  side  and 
valgum  on  the  other.  It  is  frequently  associated 
with  a  bowing  outwards  of  the  shaft  of  the  tibi?e, 
just  below  the  upper  epiphysis,  or  at  their  lower  thirds, 
and  sometimes  with  a  bowing  of  the  femora  tis  well. 
The  symptoms  are  self-evident,  and  what  has  been 
said  of  the  cause,  pathology,  and  treatment  of  genu 
valgum  will  nearly  apply  to  genu  varum,  if  external  be 
substituted  for  internal  in  the  phraseology.  Where 
tlie  tibia  and  fibula  are  much  curved,  and  the  bones 
have  become  consolidated  in  the  deformed  position, 
either  subcutaneous  Imear  osteotomy  or  the  removal  of 
a  wedge-shaped  piece  from  the  tibia,  with  fracture  of 
the  fibula,  may  also  be  required. 

Deformities  of  Great  Toe. 

Hallux  valgniis  and  hallux  varus  are  terms 
applied  to  a  deformed  and  partiallv  dislocated  great 
toe.  In  Judlux  valgus,  the  great  toe  at  the  metatarso- 
phalangeal joint  is  abducted  and  partially  dislocated 
from  the  metatarsal  bone,  and  crosses  in  extreme  cases 
either  over  or  under  the  second  and  even  the  next  toe. 
The  deformity  is  generally  attributed  to  wearing  too 
short  or  narrow-toed  boots,  but  long-standing  gout  and 
rheumatism  are  thought  by  some  to  have  some  share 


362  Manual  of  Surgery. 

in  its  production.  The  little  toe  is  often  dislocated 
inwards  at  the  same  tini'^,  whilst  the  other  toes  are 
drawn  up  claw-like  to  make  room  for  the  great  and 
little  toes  below  them.  In  long-standing  cases  the 
external  lateral  ligament  becomes  shortened,  and  the 
head  of  the  metatarsal  bone  distorted  and  thickened 
by  absorption  and  the  deposition  of  new  bone  around  ; 
whilst  in  consequence  of  the  continued  chafing  and 
pressure  of  the  boot,  the  skin  over  it  becomes  callous, 
and  a  bursa  is  generally  produced.  This  bursa  is  very 
apt  to  become  inflamed,  and  is  then  known  as  a  bunion; 
or  it  may  suppurate  and  produce  an  intractable 
ulcer ;  or  should  it  communicate  with  the  joint,  this 
also  may  be  attacked,  leading  to  caries  and  necrosis  of 
the  bones,  or  to  ankylosis.  In  old  people  such  an  ulcer 
may  become  a  starting  point  of  senile  gangrene. 

IWeatment. — Slight  cases  are  readily  remedied  by 
weari]ig  properly  shaped  boots  and  by  avoiding  too 
long  standing  and  over-walking.  The  boot  should 
have  low  heels,  and  square  toes,  be  sti-aight  along  the 
inner  edge  and  sufficiently  long  and  wide  to  allow 
plenty  of  room  for  the  toes  to  resume  their  normal 
position.  In  severer  cases  some  form  of  apparatus  for 
drawing  the  toe  into  its  normal  position  nnist  bo 
employed.  Thus  a  chamois  leather  cap  may  be  Avorn 
over  the  toe,  from  which  a  piece  of  elastic  weighing 
passes  along  the  inner  side  of  the  foot,  and  is  fixed 
round  the  heel  by  bands  of  adliesive  plaster  ;  or  a 
steel  sole  plate  having  partitions  of  a  soft  material 
for  separating  tlie  toes  may  be  worn  in  the  boot,  or 
a  wedge  may  be  fitted  to  such  a  plate  to  keep  the 
great  toe  from  its  neighbour.  At  night  a  light  shoe, 
[uovided  with  a  bunion  spring,  may  be  worn.  "  This 
s[)ring  has  an  oval  opening  over  the  bunion  to  avoid 
direct  pressure  on  the  aOcjctod  joint,  and  the  too  is 
gradually  everted  by  a  small  strap  passing  round  it, 
fixed  to  the  end  of  the  spring. " 


Hammer   Toe.  363 

The  bursa  should  be  protected  by  soap  plaister,  and 
when  enlarged  and  painful  pamted  with  tincture  of 
iodine,  or  rubbed  wuth  biniodide  of  mercury  ointment. 
Should  it  suppurate  a  free  incision  should  be  made  and 
a  poultice  applied.  The  ulcer  met  with  in  this  situ- 
ation usually  requires  a  stimulating  treatment ;  but 
when  the  opening  is  small  and  the  skin  undermined, 
it  should  be  laid  freely  open  and  the  redundant  skin 
cut  away.  In  some  cases  amj^utation  of  the  toe  may 
be  necessary. 

llcilliix  Icarus  is  very  much  less  common  than 
valgus.  In  it  the  great  toe  is  partially  displaced 
inwards  and  carried  away  from  the  other  toes,  instead 
of  towards  them  as  in  valgus.  It  may  occur  in 
talipes  equino-varus,  in  knock-knee,  in  sor.ie  para- 
lytic aliections,  from  contraction  of  the  abductor 
pollicis,  etc.  Should  it  continue  after  removal  of  the 
cause,  a  properly  shaped  boot  must  be  worn  to  keep 
the  toe  in  place,  but  tenotomy  of  the  abductor  pollicis 
may  be  required. 

IlaiiiiBier  toes, — This  term  is  applied  to  a  con- 
dition of  the  toes  in  which  the  first  phalanx  is  extended 
and  the  second  and  ungual  flexed,  so  that  the  toes 
present  a  claw-like  appearance.  It  is  generally 
present,  as  has  been  stated,  in  talipes  equinus  and 
cavus,  and  in  hallux  valgus,  but  may  be  met  with  as 
an  independent  all'ection  from  wearing  too  short  boots. 
It  is  then  generally  limited  to  the  second  or  third  toe, 
over  the  dorsal  surface  of  which  corns  commonly  form. 
Tenotomy  of  the  extensor  tendons,  and  even  ampu- 
tation of  the  first  phalanx,  may  be  necessary.  (.S'e« 
also  Talipes  cavus.) 

Siipcriiunicrary  tligitsare  frequently  associated 
with  other  deformities  as  webbed  fingers  or  toes, 
double  hands  or  feet,  club  foot,  etc.  They  appear  to 
be  hereditary,  and  often  occur  in  several  members  of 
the  same  family.     There  may  be  simply  an  increase 


364  Manual  of  Surgery. 

in  the  number  of  fingers  or  toes,  the  extra  digits  being 
either  of  normal  size,  or,  as  is  more  frequent,  shorter 
and  smaller.  But  the  most  common  abnormality  is 
a  shrunken  and  malformed  little  finger  or  thumb,  at- 
tached excrescence-like  by  a  pedicle,  often  consisting 
merely  of  skin,  though  sometimes  containing  a  slip  of 
tendon.  An  extra  toe  often  causes  no  inconvenience, 
and  need  not  be  interfered  with,  but  a  supernumerary 
finger  should,  as  a  rule,  be  amputated  at  an  early 
period.  As  it  may  articulate  with  the  metacarpal  bone 
by  a  joint  common  to  it  and  the  normal  finger,  it  is 
better  to  saw  through  the  phalanx  close  to  the  articu- 
lar surface  rather  than  to  disarticulate. 

Cong'euital  liyi>crtroi>liy. — This  rare  condition 
is  generally  limited  to  one  or  more  digits,  but  it  may 
affect  the  whole  of  one  or  more  limbs.  It  may  involve 
all  the  tissues  of  the  affected  part,  or  be  limited  to  the 
bone  or  to  the  skin  and  subcutaneous  tissue.  Some- 
times it  takes  the  form  of  a  distinct  excrescence  con- 
sisting of  subcutaneous  tissue  and  fat.  The  removal 
of  the  affected  part,  where  this  is  practicable,  is  gene- 
rally indicated. 

Dcflcieiicy  of  bones.  —  Almost  every  bone 
in  the  body  has  been  found  in  part  or  wholly 
deficient.  Amonij  the  most  common  of  such  de- 
ficiencies  may  be  mentioned  absence  of  the  radius  with 
part  of  the  carpus  and  one  or  more  fingers  in  the 
upper  extremity,  and  of  the  tibia,  with  deficiency  of 
some  of  the  tarsal  bones,  and  bones  of  the  toes  in  the 
lower.  Little  can  be  done  in  the  form  of  surgical 
treatment,  but  in  the  case  of  the  lower  extremity  some 
form  of  leg  iron  may  be  found  that  will  aid  the  patient 
in  walking. 


i^'S 


VIT.     DISEASES    OF    THE    HEAD. 

FllEDElUCK    TkKVKS 

Ki-ysipelas  <>f  the  scalp  is  common,  and  tlie 
bulk  of  the  examples  of  the  idiopathic  form  of  the 
disease  are  in  this  situation.  The  inflammation 
spreads  with  unusual  rapidity,  but  owing  to  the  tense- 
ness of  the  scalp,  redness  is  but  very  little  marked, 
and  swelling  is  inconsiderable.  Certain  cerebral 
symptoms  are  common  (headache,  vertigo,  drowsiness 
or  restlessness,  delirium),  and  depend  usually  upon 
hyperaemia  of  the  pia  mater.  Owing  to  the  possibility 
of  cerebral  complications  the  prognosis  in  erysipelas  of 
the  scalp  is  a  little  more  grave  than  that  of  erysipelas 
elsewhere.  The  form  of  the  disease  most  often  met 
with  is  that  known  as  the  "cutaneous." 

Cellulitis,  or  ditTiisc  plBleg^moii  of  tlic 
scalp,  refers  to  a  spreading  inflammation,  commonly 
erysipelatous,  that  involves  the  loose  layer  of  connec- 
tive tissue  between  the  aponeurosis  of  the  occipito- 
frontalis  and  the  pericranium.  It  is  usually  due  to 
a  wound  opening  up  that  layer  of  tissue,  but  may 
depend  also  upon  deep  ulceration,  or  upon  suppura- 
tion following  fracture,  etc. 

There  is  a  deep  rapidly  spreading  swelling.  The 
parts  are  hot,  tender,  ])ainful,  and  brawny.  Fluctuation 
ajjpears  at  certain  points.  The  constitutional  symp- 
toms  of  suppurative  fever  are  marked.  In  time  the 
whole  scalp  may  be  lifted  up,  and  may  be  found  rest- 
ing upon  a  stratum  of  pus. 

If  the  matter  escapes  spontaneously  it  usually  finds 
a  vent  in  the  temporal  or  mastoid  regions.  Sloughs  of 
the  connective  tissue  are  discliarged  ;  necrosis  may 
follow.    The  inflammation  may  extend  to  the  meninges. 


366  Manual  of  Surgery, 

or  thrombosis  of  the  cerebral  sinuses  may  follow. 
The  case  may  end  in  fatal  pyaemia.  In  favourable 
cases  prolonged  suppuration  usually  supervenes. 

Treatment. — The  head  should  be  shaved  and  free 
incisions  made  as  soon  as  suppuration  is  suspected. 
These  incisions  should  be  made  at  the  most  dependent 
spots  possible,  as  near  to  the  attachments  of  the  apo- 
neurosis as  the  swelling  extends,  and  out  of  the  way 
of  the  scalp  arteries.  The  whole  scalp  should  be 
poulticed  with  wood  wool  poultices,  and  all  the  inci- 
sions be  freely  drained.  The  ordinary  constitutional 
treatment  must  be  carried  out. 

When  the  more  acute  symptoms  have  subsided, 
the  head  may  be  compressed  by  means  of  a  Martin's 
elastic  bandage,  so  as  to  prevent  spreading  or  bagging 
of  the  pus.  All  sloughs  should  be  removed  as  soon  as 
they  are  free ;  and  the  drainage  tubes  retained  until 
the  discharge  has  become  insignificant. 

Abscess  of  the  scalp  may  be  met  with  in 
three  situations:  1.  In  the  scalp  proper,  above  the 
aponeurosis.  2.  \\\  the  lax  tissue  beneath  the  aponeu- 
rosis. 3.  Beneath  the  pericranium.  Abscesses  in 
the  first  and  third  situations  are  circumscribed,  but 
those  beneath  the  aponeurosis  are  generally  difl'nse. 
Scalp  abscesses  may  follow  contusions,  ecchymoses, 
wounds,  fractures,  the  breaking  down  of  scrofulous  or 
syphilitic  deposits,  and  bone  affections.  They  all  de- 
mand an  early  iucision,  but,  apart  from  this,  call 
for  no  special  treatment. 

Tumours  of  the  Scalp. 

IIaeiiiatoiiia.^.vCollections  of  blood  (like  ab- 
scesses) may  be  met  with  in  three  situations  :  1.  In 
the  substance  of  the  scalp  (these  are  small  and 
circumscribed).  2.  In  the  lax  tissue  beneath  the 
aponeurosis  (those  hfematomata  may  be  very  exten- 
sive,   and    may    involve    nearly    the    whole    of     the 


Hmmatoma  of  Scalp.  367 

vault,  being  limited  onl}  by  tlie  utt;icliiiients  of  the 
a]wneiirosis).  3.  Beneath  the  pericranimn.  The 
first  two  named  follow  simple  contusions,  and  de- 
mand no  special  consideration.  The  last  named  are 
usually  spoken  of  as  ccphal-hcematomata,  and  pi-e.sont 
some  points  of  interest.  They  are  met  with  in  the 
newly  born,  depend  upon  some  injury  received  during 
birth,  are  more  common  in  males  than  in  females,  and 
are  usually  situated  on  the  parietal  bone,  especially 
that  of  the  right  side.  They  usually  appear  within 
forty-eight  hours  of  birth,  and  form  soft,  elastic, 
fluctuating,  and  painless  tumours  of  variable  size. 
They  are  always  precisely  limited  by  the  pericranium, 
and  therefore  never  extend  beyond  a  suture.  In  a 
few  days  the  centre  of  the  swelling  feels  soft,  and 
around  its  margin  is  noticed  a  tolerably  hard  ring. 
The  latter  is  probably  due  to  partial  coagulation,  and 
in  old  cases  may  be  replaced  by  a  harder  ring  of  ill- 
formed  bone.  The  prognosis  is  favourable,  the  swel- 
ling disappearing  in  from  fifteen  days  to  two  months. 
The  condition  calls  for  no  treatment. 

Sebaceous  cysts  are  peculiarly  common  on  the 
scalp.  They  are  apt  to  be  nudtiple  and  may  attain  great 
size.  They  form  roundish  tumours  with  very  distinct 
walls.  They  are  movable,  possessed  of  faint  fluctua- 
tion, and  cannot  be  separated  from  the  skin.  When 
of  large  size  the  hair  that  co\ers  them  atrophies,  and 
the  tumour  becomes  bare.  They  are  of  very  slow 
growth,  may  remain  stationary  for  an  indefinite  time, 
are  painless,  and  contain  altered  sebaceous  matter  and 
epideiinal  debris.  Many  present  a  black  point  upon 
their  sunnnits.  They  are  apt  to  suppurate  if  in- 
jured. 

When  suppuration  occurs  the  skin  in  time  gives 
way,  the  sebaceous  matter  protrudes,  and  granulations 
spiing  up  from  the  exposed  sac  wall.  In  this  way 
a  I'ungating  vascular  mass  (the  follicular  or  fun(jating 


368  Manual  of  Surgery. 

iilcer  of  iJifi,  scalp)  may  he  produced,  which  closely  re- 
sembles epithelioma.  From  this  disease,  however,  it 
may  be  separated  by  the  history  of  the  case,  by  the 
previous  existence  of  a  sebaceous  cyst,  by  the  absence  of 
any  infiltration  at  the  margins  of  the  sore,  and  of  any 
enlargement  of  lymphatic  glands.  The  only  mode  of 
treating  so])aceous  cysts  is  by  excision. 

Con^oiaital  <1ci*isioi«l  cysts  resemble  the  seba- 
ceous cyst  in  most  points.  They  are,  however,  small, 
seldom  exceeding  a  diameter  of  two-tliirds  of  an  inch, 
are  of  very  slow  growth,  are  congenital,  and  contain  in 
addition  to  sebaceous  matter,  as  a  rule,  a  number  of 
fine  hairs.  They  are  most  common  at  the  outer  angle 
of  the  orbit,  and  always  have  deep  connections  with 
the  pericranium.  They  may  lie  in  actual  depres- 
sions in  the  cranial  bones.  They  should  be  excised 
when  possil)le,  but  those  about  the  orbit  have  often 
such  deep  connections  as  to  render  complete  excision 
impossible  or  inadvisable. 

Iffoi'iis. — These  strange  excrescences  are  developed 
from  the  interior  of  a  sel)aceous  cyst  that  has  been 
opened  up  by  rupture  or  inflammation.  They  are 
formed  of  sebaceous  matter  that  has  become  dry  and 
horny  from  exposure.  As  fresh  matter  is  constantly 
being  produced  by  the  cyst  wall  at  its  base  the  horn 
grows.  Some  have  attained  the  length  of  six  or  eight 
inches.  They  can  be  best  treated  by  carefully  excising 
their  bases,  including  the  whole  of  the  remains  of  the 
sebaceous  cyst. 

Pacliytlcriiiatocclo. — This  remarkable  affection 
is  also  known  as  elephantiasis,  and  as  hypertrophy  of 
the  scalp.  It  consists  of  an  immense  over-growth  of 
the  scalp  tissues.  The  tumour  formed  consists  mainly 
of  connective  tissue,  and  hangs  down  as  a  huge  pendu- 
lous tumour,  tliat  is  often  lobulated,  is  flabby  to  the 
touch,  is  painless,  and  covered  by  normal  skin  (Fig.  82). 
The  tumour  may  cover  the  eyes  and  even  drag  ui)on 


Pne  uma  tocel  l  . 


369 


the  moutli.  It  is  innocent,  and  causes  distress  only  by 
its  bulk.  In  some  cases  it  is  congenital,  in  otlieivs  it 
appears  at  puberty  or  in  young  adults.  It  is  most 
common  about  the  temporjil  or  parietal  regions.  Some 
benefit   may    attend    the 


use    of     long    continued 


Fig.  82. — Pachydermatocele. 


pressure,  but  if  this  fails 
excision    offers    the   only 
alternative  treatment. 
Piiciiiiiatoecle.  — 

This  name  is  given  to  a 
tumour  containing  air ; 
the  collection  is  bcnea.th 
the  pericranium.  Pneu- 
matocele is  usually  met 
with  over  the  mastoid 
process ;  one  case  has 
been  described  as  existing 
over   the    frontal    sinus. 

The  mastoid  cells  or  frontal  sinus  have  become  per- 
forated, and  air  finds  its  way  under  the  pericranium 
from  the  middle  ear  in  the  one  case,  and  from  the  nose 
in  the  other.  The  perforation  may  be  due  to  accident, 
to  caries  sicca,  or  to  atrophy  of  the  Ttony  walls  of  the 
cells  or  sinus.  The  tumour  is  small,  round,  painless, 
and  tympanitic.  By  jiressure  it  may  be  made  to  dis- 
appear. Its  progress  is  exceedingly  slow,  and  it 
usually  produces  no  trouble.  It  should  be  treated 
simply  by  the  pressure  of  a  carefully  applied  pad. 

In  addition  to  thrf;e  special  tumours,  the  following 
are  also  to  be  met  with  in  the  scalj^  :  Na^vi ;  cirsoid, 
racemose,  and  arterio- venous  aneurisms  ;  arterial 
varix ;  sarcomata ;  fatty,  fibrous,  and  papillomatous 
growths.  The  three  last  named  are  very  rare. 
These  tumours,  differing  in  no  essential  respect  from  like 
growths  found  elsewhere,  demand  no  especial  notice. 
Nsevi  and  arterial  angeiomata  are  more  common  on  the 
Y— 21 


37©  Manual  of  Surgery. 

head  than  in  any  other  part  of  the  body.  The  first  named 
are  most  often  met  with  about  the  anterior  fontanel le, 
the  orbit,  and  the  temple,  and  the  latter  in  connection 
with  the  temporal,  posterior  auricular,  and  occipital 
arteries. 

Affections  of  the  Skull, 

I?lA'B«Biia;:occlc ;  CBB<;€'|»lisEloccle,  liy<1mice- 
l»lialo«'X'lo. — These  terms  are  .'ipplied  to  certain  tumours 
that  consist  essentially  of  a  protrusion  of  some  part  of 
the  cranial  contents  through  an  aperture  in  the  skull. 
They  are  all  congenital.  When  the  tumour  contains  a 
protrusion  of  the  meninges  only,  the  term  meningocele 
is  used  ;  when  a  protrusion  of  brain,  the  term  encepha- 
loccle  ;  and  when  the  mass  is  formed  by  a  portion  of 
brain,  greatly  distended  with  lluid  from  a  dropsical 
ventricle,  it  leceives  the  name  of  hydrencephalocele. 

Of  these  three  tumours  the  last  named  is  the  most 
couimon,  while  the  pure  meningocele  is  the  most  rare. 

These  protrusions  depend  upon  congenital  defects 
in  the  development  of  the  skull,  whereby  gaps  are  left 
in  the  cranial  bones. 

Situation. — The  most  common  site  is  the  occipital 
region,  where  the  gap  is  found  about  the  middle  line 
of  the  occipital  bone,  and  wlience  it  may  extend  to  the 
foramen  magnum  or  the  posterior  fontanelle. 

The  site  next  in  fre([uency  is  the  root  of  the  nose, 
the  protrusion  leaving  the  skull  between  the  cribriform 
plate  and  the  frontal  bone,  and  appearing  externally 
between  the  frontal  and  nasal  boncis.  Tumours  in  this 
site  are  usually  much  smaller  than  those  on  the  occi- 
put, and  being  very  often  covered  by  red  and  vascular 
skin,  liave  been  mistaken  for  luevi.  The  I'arest  situa- 
tion is  at  some  j^oint  (usually  at  a  siil.ure  ]in(i)  abtmt 
the  sides  or  base  of  the  skvdl.  Tumours  developed  in 
the  latter  situation  have  projected  into  the  orbit,  the 
mouLh,  and  the  pharynx. 


Meningocele, 


371 


Symjjtonis. — These  protrusions  appear  as  roundish 
elastic  tumours,  covered  usually  by  normal  skin, 
which  may,  however,  be  greatly  tliinned  and  also  ex- 
coriated. They  usually  have  a  pulsation  synchronous 
with  the  heai't,  and  may  be  reduced  more  or  less  by 
pressure,  such  reduction  being  often  followed  by  brain 
sym})toms  (headache,  vomiting,  convulsions,  stupor,  etc.). 

They  are  often  pedunculated  and  pendulous.  The 
hole  in  the  skull  can  usually  be  made  out.  On  forcible 
expiration  the  tumour  as  a  rule  becomes  more  tense  or 
increases  in  size.  If  the  mass  be  small  the  skull  will 
be  normal  in  outline  ;  if  large,  the  child  will  be  micro- 
cephalic. 

The  separate  symptoms  and  the  features  in  the 
differential  diamosis  are  exhibited  in  the  followintj 
table. 


Size  aud 
Surface. 

Pedicle. 

Fluctuation. 

Meningocels     . 

ENCEPirAT.OCELE 

Hydbencepualocele, 

Small.     Surface 
smooth. 

Small.     Surface 
smooth. 

Often  large  aud 
peudulous.  Sui"- 
face  ofteu  in-e- 
gular  or  lobed. 

As    a   rule    pe- 
dunculated. 

Wide  ba.se. 

Earely     peduu- 

culated. 

As    a    ride    pe- 
dunculated. 

Most  distinct. 
Absent. 

Distinct. 

Ti-auslucency. 

Pulsation. 

Reducibility. 

M;eningk)cele     . 

Ekcephalocele 

Hydkencephalocele. 

Perfect. 

Opaque. 

T  r  a  u  s'l  u  c  e  n  t 
ouly    at    most 
dcpeudeut     or 
most       promi- 
ueut  parts. 

Earely  present. 

Distinct. 
Raroly  present. 

Always  redu- 
cible. 

Reducible,    but 
not  completely. 

Irreducible. 

372 


Manual  of  Surgery. 


Prognosis. — The  majority  of  the  subjects  of  these 
dt^foi'inities  die  within  a  short  period  of  birtli.  In 
hydrencephiilocele  the  prognosis  is  absolutely  bad  ;  in 
meningocele  it  is  the  least  hopeless.  In  most  cases 
the  tumour  increases,  and  in  time  bursts,  causing 
death  from  collapse,  convulsions,  or  acute  meningitis. 
It  may,  however,  i-emain  stationary,  and  the  patient 
may  attain  adult  life.  In  the  case  of  meningocele, 
the  bony  gap  may  become  so  narrow   that  the  cavity 

of  the  tumour  is  cut 
oft'  from  the  cranial 
cavity,  and  a  sponta- 
neous cure  follows. 

Treatment  —  Tlie 
mass  should  be  simply 
protected.  Operative 
interference  is  only 
justifiable  under  one 
condition,  viz.  when 
rupture  of  the  tumour 
is  threatening.  1. 
Empty  the  sac  with  a  capillary 
trocar,  and  repeat  the  tapjnngs  as  the  sac  refills. 
This  has  resulted  in  cure.  If,  however,  the  sac 
re-lill  in  a  shorter  time  after  each  tapping,  and  the 
fluid  )>ecome  dull,  injections  of  iodhie  may  be  used 
(tr.  iodi.  one  part,  water  two  parts) ;  this  measure  has, 
however,  met  with  little  success.  As  an  alternative 
the  excision  of  the  sac  under  antiseptic  precautions 
may  be  entertained.  2.  Encephalocele,  Repeated 
tappings  (if  there  be  fluid  in  the  sac),  followed  by 
pressure  by  means  of  an  elastic  bandage,  may  be 
employed.  3,  Hydrencephalocele  is  not  adapted  for 
any  operative  interference. 

Caries  and  necrosis.— Caries  of  the  skull  is 
less  connnon  than  necrosis,  and  may  be  due  to  injury, 
to  syphilis,  or  to  scrofula.    It  is  most  often  met  with  on 


HycU'eiicephaloccle. 


Meningocele 


A^ECROSIS   OF   THE   Sh'ULL.  373 

the  extornal  table,  bnt  may  commence  in  the  inner 
table  or  the  cli2)loe.  The  l)ones  usually  involved  are,  in 
order  of  frequency,  the  frontal,  the  mastoid,  and  the 
occipital.  The  disease  may  be  very  extensive,  and  in 
any  form  the  cranial  vault  may  be  perforated.  This 
perforation  may  occur  at  many  spots,  especially  in  the 
sy])hilitic  form,  and  through  the  holes  so  formed  the 
pulsations  of  the  brain  may  be  recognised.  In  such 
cases  tlio  dura  mater  is  thickened  by  inflammatory 
deposit. 

The  pathology  and  general  symptoms  of  the 
affection  do  not  differ  from  those  of  caries  elsewhere. 
The  gravity  of  the  disease  depends  to  a  great  extent 
upon  certain  special  complicatiojis.  These  are 
pysemia  from  suppurative  phlebitis  of  the  diploic 
veins,  thrombosis  of  the  cerebral  sinuses,  collections 
of  pus  between  the  dura  mater  and  the  bone, 
meningitis  of  the  convexity,  and,  in  rare  cases, 
abscess  of  tlie  brain. 

Treatment. — Treat  the  constitutional  condition. 
Evacuate  all  collections  of  pus  j  keep  the  parts  clean. 
If  the  caries  be  sj^reading,  a  cautious  use  of  tlie 
gouge  may  be  advised.  If  pus  be  pent  up  either  in 
the  substance  of  the  bone  or  beneath  the  dura  mater, 
the  application  of  the  trephine  is  called  for.  In 
many  cases,  also,  of  early  spreading  caries,  the 
trephine,  not  necessarily  applied  through  the  whole 
thickness  of  the  skull,  may  arrest  the  disease. 

Necrosis  may  follow  contusions,  lacerations  of 
the  scalp,  fractures,  burns,  and  extravasations  of  blood 
beneath  the  pericranium  or  the  dura  mater,  or  it  may 
follow  the  eruptive  fevers,  or  depend  upon  scrofula 
or  tertiary  sy})hilis.  The  last  named  cause  is  the 
most  common  of  all. 

In  the  idiopathic  forms  the  frontal  and  pnrietal 
bones  are  most  often  involved.  The  whole  thickness 
of  the  bone  may  necrose,  but  more  usually  the  disease 


374  Manual  of  Surgery. 

involves  only  the  outer  table.  In  very  rare  cases  it 
has  involved  only  the  inner  table. 

The  necrosis  is  usually  limited,  but  it  may  be 
very  extensive,  and  in  some  recorded  cases  nearly  the 
whole  of  the  vault  of  the  skull  has  been  lost  by 
necrosis  in  the  process  of  years. 

The  mode  of  separation  of  the  sequestrum  is  the 
same  as  that  observed  in  necrosis  elsewhere  {see  Art. 
II.,  page  124),  and  the  only  pathological  feature  special 
to  skull  necrosis  is  the  absence  of  any  new  bone  for- 
mation. The  sequestrum  is  not  retained  or  invaginated 
by  new  bone,  and  the  gaps  left  in  the  cranium  after 
the  separation  of  the  sequestra  are  filled  up  by  fibrous 
tissue  only.  The  special  complications  that  may 
attend  caries  may  attend  necrosis. 

Treatment. — Give  free  exit  to  all  discharges. 
Superficial  necrosis  may  be  practically  left  to  itself, 
or  the  process  of  exfoliation  may  1)e  aided  by  the  use 
of  strong  sulphuric  acid.  Remove  all  loose  sequestra. 
If  the  dead  piece  be  too  large  for  convenient  removal, 
it  may  be  trej)hined  and  removed  in  segments.  The 
trephine  may  also  be  used  when  pus  collects  between 
the  dura  mater  and  the  bone. 

Tiiiiioiirs  of  tlie  skull.  Ostcoinata. — Those 
bony  tumours  that  grow  from  the  outer  table  of  the 
skull  are  called  exostoses,  those  springing  from  the 
diplon  or  inner  table  enostoscs.  Some  are  spongy  or 
cancellous  in  structure,  but  the  majority  have  the 
structure  of  ivory  exostoses.  These  tumours  are 
often  multijile,  sometimes  symmetrical,  and  are  most 
commonly  found  in  connection  with  the  frontal  bone, 
and  next  in  frequency  with  the  mastoid  and  occipital 
bones.  They  are  usually  iiTegular  and  bossy  ;  they  are 
of  slow  growth,  and  only  cause  trouble  when  they 
coui  press  the  brain  (enostoses)  or  grow  into  the  orbit 
or  nose.  P]xostoses  in  the  latter  sites  may  necrose  en 
masse.     In  the  great  majority  of  cases  these  tumoui'S 


Fungus  of  the  Dura  Mater.  375 

call  for  no  opo.rativc  interference,  and  arc  indeed 
affected  Ly  none. 

In  very  rare  instances  the  following  grotvths  have 
been  met  with  in  tlie  skull.  Hydatid  cysts  ;  angeio- 
mata ;  sarcomata  growing  from  the  pericranium  or  the 
diploe.  These  tumours  are  usually  of  the  spindle- 
celled  variety,  and  are  more  often  secondary  than 
primary.  If  growing  from  the  diploe  they  ex- 
pand the  outer  table,  and  for  a  time  form  tumours 
with  thin  bony  shcdls.  They  are  beyond  treat- 
ment. 

Carcinoma  of  the  skull  is  met  with,  Imt  always  as 
a  secondary  affection. 

Fiiiig:iis  of  the  dura  mator. — This  term  is 
applied  to  a  sai'comatous  tumour  growing  from  tlie 
dura  mater  (and  in  very  rare  instances  from  the  j)ia 
mater  or  arachnoid)  that  has  penetrated  the  cranium, 
and  has  appeared  under  the  scalp. 

The  growths  may  be  primary  or  secondary.  The 
former  are  the  less  common  and  are  single,  the  latter 
are  due  to  metastasis  and  are  often  multiple.  This 
form  of  sarcoma  is  rare,  since  the  majority  of  the 
sarcomata  of  the  dura  mater  do  not  perforate. 

Symptoms. — In  most  cases  no  symptoms  precede 
the  appearance  of  the  external  tumour.  In  other 
cases  there  are  cerebral  symptoms  (headache,  neuralgia, 
vertigo,  vomiting,  convulsions,  etc.).  As  the  tumour 
makes  its  way  through  the  bone,  a  soft  spot  of  thinned 
bone  may  perhaps  be  felt  at  the  vertex,  which  crackles 
on  pressure.  This  thin  bone  gives  way,  and  the 
sarcoma  protrudes  as  a  small  flat  firm  tumour  that 
pulsates  and  can  be  reduced  on  pressure ;  on  reduction 
the  hole  in  the  skull  may  be  made  out.  The  mass 
soon  grows,  and,  s})reading  beyond  the  hole,  becomes 
more  prominent  and  softer,  and  at  the  same  time 
irreducible  and  no  longer  pulsating.  If  the  patient 
lives  long  enough  the  mass  may   fungate  through   the 


376  Manual  of  Surgery. 

Bcah)  tissues.  Sarcomata  crowinc:  from  the  Ijone  are 
harder,  are  never  recUicibk-,  and  never  jmlsate. 

The  affection  is  rapidly  fatal,  and  is  beyond  the 
reach  of  any  but  palliative  treatment. 

Hypciti'opliy  of  the  <»kiill. — 1.  Some  few  cases 
oi  simple  hypertrophy  have  been  noted.  The  subjects 
have  usually  been  advanced  in  life.  The  hypertrophy 
has  involved  the  entire  skull  evenly,  or  has  been 
limited  to  some  portion  of  it.  The  cau.se  of  the 
condition  is  unknown. 

2.  Osteo-porosis. — This  term  is  applied  to  certain 
large  thick  skulls  with  obliterated  sutures,  the  bones 
of  which  on  section  appear  uniform  and  finely  porous 
like  white  brick.  The  general  shape  of  the  skull  is,  as 
a  rule,  not  altered,  but  the  component  bones  may  be 
four  or  live  times  their  normal  thickness.  Tliis 
change  is  more  or  less  entirely  limited  to  the  vault  of 
the  skull.  In  some  eases  this  peculiar  hypertrophy 
has  been  associated  with  osteo-malacia,  and  in  other 
instances  with  osteitis  deformans.  In  the  latter 
affection,  however,  the  bones  are  usually  quite  dense 
on  section,  and  the  dimensions  of  the  skull  are  greatly 
increased  in  all  its  diameters.    {See  Art.  11.,  page  120.) 

3.  In  leontiasis  ossium  the  skull  is  thickened  and 
deformed  by  the  growth  of  irregular  bossy  masses  of 
rough  and  porous  bone.  These  masses  may  be  very  large, 
are  often  symmetrical,  and  produce  great  deformity. 
The  frontal,  parietal,  and  malar  bones  are  most  often 
affected,  the  orbits  and  nasal  fosss^e  may  be  encroaclied 
upon,  and  certain  cf  the  cranial  foramina  closed.  It 
appears  usually  at  or  before  ])uberty,  and  is  of  un- 
known origin.  Pressure  symptoms  of  various  kinds 
may  arise. 

No  form  of  hypertrophy  of  the  skull  is  amenable 
to  any  but  palliative  treatment. 

Cliroiiie  liytU-oceplialiis.— This  tenn  is  ap- 
plied to  a  disease  of    young   children    characterised 


H\  PROCEF/fA  L  US. 


377 


by  cort.iin  accumulations  of  fluid  within  the  cranial 
cavity.  The  fluid  may  1)0  within  the  ventricles  (inter- 
nal hydrocephalus),  or  in  the  subdural  space  (external 
hydrocephalus). 

Internal  hydrocephalus  is  the  usual  form.  The 
ventricles  are  enormously  distended,  the  ganglia  flat- 
tened out,  the  convolutions  unfolded,  and  the  brain 
matter    very   greatly   thinned.     In    severe    ca.ses  the 


Fig.  84.— Chronic  Hytlrocepliihis. 


covering  of  brain  matter  may  not  be  more  than  half 
to  a  quarter  of  an  inch  thick  over  the  most  distended 
parts  of  tlie  ventricle.  Tlie  head  enlai-ges,  the  bones 
are  separated,  and  the  fontanelles  and  sutures  become 
of  considerable  width.  The  orbital  plate  of  the  fron- 
tal is  thrust  down,  and  the  cavity  of  the  orbit  becomes 
greatly  narrowed.  The  zygomatic  fossre  are  tilled  up, 
the  scalp  is  full  and  tense,  and  covered  by  prominent 
veins.  Fluctuation  may  be  detected  in  the  gaps  be- 
tween the  bones. 

External  hydrocephalus  cannot  be  detected  from  the 
internal  form  except  in  this,  that  there  is  in  the  present 


378  Manual  of  Surgery. 

variety  no  displacement  downwards  of  the  orbital  plate 
of  the  frontal  bone. 

The  prognosis  is  bad.  Tlie  great  majority  die  of 
exhaustion,  or  of  coma,  or  convulsions,  or  even  acute 
cerebral  mischief  The  cases  where  the  child  has 
grown  up  to  adult  life  or  even  survived  a  few  years 
are  quite  rare. 

Treatment. — With  the  general  treatment  of  the 
disease  the  present  article  has  no  concern.  The  local 
treatment  proposed  in  certain  cases  consists  (1)  in  the 
use  of  pressure,  and  (2)  in  paracentesis. 

1.  Pressure  may  be  applied  by  means  of  strapping 
or  an  elastic  bandage.  It  is  merely  a  palliative 
measure  that  may  do  good  in  some  cases,  while  in 
others  it  excites  cerebral  symptoms,  and  cannot  be 
borne. 

2.  Paracentesis  has  met  with  so  little  success  that 
the  operation  is  now  seldom  practised.  It  has  afforded 
tem]iorary  relief  in  a  few  instances,  and  has  appeared 
to  clieck  the  disease  when  progressing  rapidly.  A  very 
fine  trocar  is  entered  at  the  coronal  suture,  about 
one  inch  from  the  anterior  fontanelle,  and  is  pushed 
downwards  and  backwards ;  only  a  small  quantity  of 
fluid  is  drawn  oft'  at  a  time. 

The  use  of  iodine  injections  in  hydrocephalus  has 
been  only  attended  by  unsatisfactory  results. 

Remove  a  of  cerelM'nl  titmoiirs. — This  pro- 
cedure has  been,  so  far,  adopted  in  one  case  only.  Tlie 
surgeon  was  Mr.  Godlee ;  the  physician  in  charge  of 
the"^  case.  Dr.  Hughes  Bennet.*  The  patient  was  a 
man,  aged  25.  His  chief  symptoms  were  agonising 
headache,  vomiting,  optic  neuritis,  and  paralysis  of 
the  left  upper  limb. 

There  were  no  external  evidences  of  tumour.  Dr. 
Bennet  diagnosed  a  tumour  of  the  cortex,  at  the 
niiddj.e  third  of  the  fissure  of  Rolando,  and  at  this 
*  Med.-Chir.  Trans.,  1882. 


Cerebral  Tumours.  379 

spot  a  glioma  the  size  of  a  walnut  was  discovered  at 
tlie  operation.  The  opening  in  the  skull  was  made 
by  three  trephine  holes,  each  with  a  diameter  of  one 
inch.  The  growth  was  removed  by  means  of  Yolk- 
man's  scoop.  Bleeding  was  arrested  by  the  cautery. 
The  procedure  was  conducted  under  Listerian  pre- 
cautions. The  operation  did  not  affect  the  patient's 
intelligence,  and  led  to  no  special  disturbance.  His 
symptoms  were  for  a  while  much  improved.  Un- 
fortunately the  wound  became  septic,  a  hernia  cerebri 
formed,  and  the  patient  died  at  the  end  of  four  weeks 
of  meningitis.  But  for  this  surgical  accident  there  is 
every  reason  to  suppose  that  the  case  would  have 
resulted  in  complete  cure. 


3  So 


VUL     INJURIES  OF  THE  HEAD. 

Anthony  II.  Corley. 
Injuries  op  the  Scalp. 

Injuries  of  tlie  scalp,  tliougli  always  of  im- 
portance, yet  frequently  become  of  secondary  interest, 
in  consequence  of  being  accompanied  by  some  lesion 
of  tlie  skull  or  its  contents.  Whilst  subject  to  the 
same  classification  as  injuries  of  other  regions,  the 
peculiar  anatomical  structure  in  which  they  occur 
often  gives  scalp  wounds  a  character  of  their  own. 
Notwithstanding  the  frequency  and  triviality  of  "  cut 
heads,"  there  is  generally  a  disposition  to  over-rate 
their  gravity,  first,  because  of  their  possible  compli- 
cation with  deeper  injuries ;  and  secondly,  because  of 
an  old  and  deeply-rooted  belief  that  they  are  more 
likely  to  be  followed  l)y  erysipelas  and  allied  diseases 
than  arc  wounds  of  other  regions. 

They  may  be  divided  thus :  A.  Contusions.  B. 
Wounds.  The  latter  may  be  subdivided  into  (1) 
incised,  (2)  contused,  (3)  lacerated,  (4)  punctured, 
(5)  poisoned,  (G)  gun-shot,  and  (7)  "  fiap  "  wounds, 
these  last  being  usually  a  combination  of  contused 
and  lacerated  injuries,  worthy  of  particular  mention. 

Before  entering  upon  a  description  of  these 
lesions,  it  may  be  well  to  glance  at  the  anatomical 
arramjrmcnts  which  confer  special  characters  on  some 
of  these  injuries. 

The  scalp  is  a  complex  structure  tightly  covering, 
but  movable  upon,  the  cranium.  Its  principal  com- 
ponents are  :  the  skin  with  its  appendages,  and  tlie 
occipito-frontalis  muscle  with  its  intervening  tendon, 
the  epicranial  aponeurosis.    Of  great  importance,  from 


Injuries  of  the  Scalp.  381 

a  surgical  point  of  view,  are  two  planes  of  con- 
nective tissue,  one  between  the  skin  and  subjacent 
ai)oneurosis,  and  the  second  separating  the  aponeu- 
rosis from  the  pericranium.  The  first  or  exterior 
layer  of  connective  tissue  is  of  a  dense,  fibrous  cha- 
racter, containing  in  its  substance  the  blood-vessels 
and  nerves  ;  whilst,  as  the  muscle  is  to  glide  freely 
over  the  cranial  vault,  the  layer  beneath  it  is  of  a 
loose  character,  readily  torn  and  sparingly  supplied 
with  blood.  Removal  of  the  scalp,  for  whatever 
purpose,  is  effected  by  tearing  through  this  in- 
ferior layer,  and  is  a  process  very  readily  performed. 
Pus  formed  within  the  supeiiicial  plane  most  com- 
monly  constitutes  an  abscess,  and  blood  in  the  same 
position  a  circumscribed  tumour,  but  when  either  is 
found  in  the  deeper  connective  tissue  layer  it  forms 
a  diffuse  swelling,  tending  to  project  in  tlie  direction 
of  the  eyelids  or  ears. 

Tlie  fact,  too,  that  the  copious  blood  and  nerve 
supply  of  the  scalp  lies  in  the  subcutaneous  connective 
tissue,  explains  the  well-known  axiom  that  practi- 
cally the  scalp  never  sloughs ;  for,  though  it  is  true 
that  a  portion  of  it  may  be  destroyed  by  direct  injury 
or  pressure,  yet  the  mortification  is  limited  to  the 
part  immediately  involved.  In  the  case  of  the 
scalp,  deep-seated  suj^puration  is  powerless  to  destroy 
the  vitality  of  the  superficial  parts,  wl-.ose  blood- 
vessels the  pus  can  neither  strangle  nor  destroy. 
The  lymphatic  vessels  of  the  scalp  are  numerous,  and 
seem  specially  prone  to  propagate  the  results  of  irrita- 
tion of  their  peripheral  ends  to  the  glands  in  the  neck. 

A.  Coiitusioiis  of  tlic  scalp  may  be  divided 
into  those  special  to  now-born  children  and  those 
found  at  all  other  periods  of  life. 

The  former  are  the  direct  result  of  injury  during 
parturition.  Amongst  them  the  ordinary  scalp  tumour 
or  caput  succeda7ieu7nj  found   in  most  cases  of  head 


382  Manual  of  Surgery, 

presentation,  can  scarcely  be  reckoned  as  a  morbid 
condition,  inasmuch  as  it  is  caused  by  mei'e  local  con- 
gestion and  cedema  due  to  mechanical  obstruction  of 
the  venous  trunks  by  the  contracted  os  uteri.  When, 
however,  the  constriction  has  been  more  considerable 
or  has  lasted  longer,  some  of  the  dilated  blood-vessels 
may  be  ruptured  and  an  extravasation  take  place, 
in  which  case  a  more  serious  condition  results,  and 
a  tumour  is  formed  which  has  received  the  name  of 
cephal-ha3matoma.  {See  Article  on  Diseases  of  the 
Head.) 

The  other  contusiones  iieonatorum  are  localised  and 
small,  and  are  produced  by  direct  violence,  either  from 
matei'ual  structures  or  from  obstetric  instruments. 

These  contusions  vary  in  intensity  and  eifects ; 
slight  ones  tend  to  rapid  resolution,  but  a  greater 
degree  of  pressure  may  result  in  ulceration  or 
sloughing.  The  natural  vitality  of  the  infantile 
structures  usually  influence  even  those  conditions,  and 
frequently  the  morbid  action  terminates  in  healing,  but 
sometimes  more  severe  consequences  ensue,  such  as 
shock,  localised  spasm,  or  paralysis. 

Contusions  at  other  periods  of  life  vary  in  extent 
from  the  slightest  subcutaneous  ecchymosis  to  the 
formation  of  a  bloody  tumour,  and  when  they  occur  in 
the  supra-orbital  region  they  may  present  special  and 
important  local  complications. 

The  simple  contusion  requires  no  special  descrip- 
tion, nor  does  it  call  for  any  special  treatment. 

The  traumatic  bloody  tumour  of  the  scalp,  how- 
ever, requires  a  special  description,  and  it  is  not 
always  possible  to  say,  with  certainty,  into  which  plane 
of  connective  tissue  the  blood  is  extra vasated.  Though 
usually,  when  the  tumour  is  large,  the  extravasation 
is  under  the  epicranial  aponeurosis ;  in  many  cases  its 
presence  is  complicated  by  a  fracture  of  the  skull, 
when  it  may  lie,  possibly,  under  the  pericranium. 


Cephal-Hmma  TOM  a  .  383 

The  cause  of  the  tumour  is  usually  a  severe  injury, 
such  as  a  blow  of  a  heavy  instrument,  or  a  fall  on  the 
head  from  a  height.  A  soft  fluctuating  tumour  is 
in  these  cases  readily  felt,  yielding  to  pressure  at 
its  centre,  but  giving  the  feeling  of  having  a  hard  and 
sometimes  api^arently  sharp  margin,  a  distinction  ^vhich 
results  from  the  fact  that  the  central  portion  contains 
tluid,  and  the  circumference  coag\dated,  blood. 

The  diagnosis  between  such  an  extravasation  and 
a  depressed  fracture  of  the  skull  is  easily  laid  down, 
but  not  always  so  easily  made  ;  and  instances  are  not 
infrequent  in  which  surgeons  of  great  experience  have 
been  doubtful  or  even  mistaken  in  their  judgment. 
These  doubts  arise  from  the  fact  that  the  centre  of  the 
tumour  is  sometimes  so  soft,  and  the  hard  margin  so 
sharply  deiined,  that  the  sensation  it  conveys  to  the 
touch  strongly  suggests  a  fracture  with  depression,  es- 
pecially as  the  cause  of  the  injury  may  have  been  of  such 
a  nature  as  to  produce  depression.  But  then,  the  sur- 
geon is  to  remember  that,  in  the  case  of  a  fracture,  the 
finger,  when  palpating  the  margin,  passes  at  once  from 
the  level  of  the  surrounding  surface  into  the  depression, 
whereas,  in  the  case  of  bloody  tumour,  the  finger  first 
passes  up  the  elevated  margin  of  the  coagulated  blood 
before  it  dips  into  the  central,  yielding,  fluid  portion  ; 
and,  if  pressure  enough  be  made,  the  tip  of  the  finger, 
displacing  the  blood,  feels  at  length  the  resistance  of 
the  subjacent  bone.  In  reference  to  this  last  test, 
it  must  be  remembered  that  its  use  would  not  be  jus- 
tifiable if  any  reasonable  grounds  existed  for  thinking 
that  the  case  was  one  of  depressed  fracture,  as  such 
pressure  might  then  be  highly  injurious.  It  may  be 
pleaded  in  justification  of  doubts,  or  nus takes  in  the 
diagnosis  of  the  two  conditions,  that  extravasation 
and  fracture  may  co-exist. 

As  regards  treatment,  the  part  must  be  as  little 
disturbed  as  possible,  and  absorption  must  be  aided 


3^4  Manual  of  Surgery. 

by  discutient  lotions.  The  extravasation  will  probably 
be  absorbed  in  time.  No  incision  is  necessary  unless 
suppuration  be  imminent  or  have  ah'cady  occurred, 
when  any  delay  in  opening  and  evacuating  the  tumour 
is  fraught  Avith  e^■il  consequences. 

Injuries  imjilicating  the  supra-orbital  re<jionSy 
whether  or  not  they  are  accompanied  l)y  signs  of  con- 
tusion, have  been  frequently  followed  by  sudden  loss 
of  vision  ;  and  for  this  reason  they  deserve  special 
mention.  The  theory  formei'ly  accepted  was,  that  the 
loss  of  sight  depended  on  injury  of  the  supra-orbital 
nerves,  producing,  by  a  reflex  process,  a  loss  of  func- 
tion in  the  retina,  and  we  find  not  infrequently  in  the 
older  books  the  heading,  "Amaurosis  from  supra- 
orl)ital  injury."  The  ophtlialmoscope,  however,  has 
revealed  the  fact  that,  in  these  cases,  dislocation  of  the 
lens,  retinal  detachment,  and  retinal  ha3morrhage  often 
occur,  and  thus  afford  a  more  reasonable  ex})lanation 
of  the  loss  of  sight  than  was  conveyed  by  the  term 
reflex  amaurosis. 

B.  Wounds. — Incised.  Ordinary  incised  wounds 
of  the  scalp  require  little  descri[)tion  other  than 
tliat  applicable  to  similar  injuries  occurring  elsewhere, 
and  they  present  no  immediate  danger,  save  that 
of  ha3morrliage,  for  controllhig  which  there  arc 
greater  facilities  here  than  in  other  regions.  When 
the  cut  is  perpendicular  to  the  subjacent  bone  the 
surface  around  should  be  shaved,  the  edges  brought 
closely  together  and  held  in  apposition  by  strips  of 
plaister,  and,  this  being  done,  immediate  union  may  b(^ 
looked  for.  Should  a  vessel  have  been  divided,  a  i)ad 
of  lint,  fixed  by  a  few  turns  of  a  bandage,  is  usually 
suflicient  to  restrain  bleeding,  as  the  bone  aflbrds 
steady  counter-})ressure.  In  case  the  bleedi]ig  persists 
it  may  be  found  to  depend  upon  the  fact  that  an 
artery  has  been  only  partially  divided,  in  which  case 
the  point  of  a  scalpel  will  soon  remedy  the  difliculty, 


Wounds  of  the  Scalp.  385 

and  allow  the  pressure  to  act  more  efficiently.  In 
some  wounds,  especially  in  those  necessarily  inflicted 
in  operations  on  the  head,  the  bleeding  point  in  the 
cut  edge  of  the  scalp  can  be  seen.  Here  a  special 
procedure  is  necessary,  for  it  is  difficult,  and  often  im- 
possible, to  tie  the  vessel,  inasmuch  as  it  is  so  closely 
embraced  by  the  fibres  of  the  first  connective  layer, 
that  it  cannot  be  drawn  out  sufficiently  to  allow  a 
ligature  to  encircle  it.  It,  however,  can  be  crossed  by 
an  acupressure  needle,  with  or  without  the  additional 
aid  of  a  twisted  suture.  When  the  wound  is  in  the 
temporal  region,  it  is  better  to  use  the  ligature  or 
needle  at  once  than  the  pad,  as  the  temporal  fascia 
does  not  bear  pressure  well. 

If  the  direction  of  the  cut  be  oblique,  and  if  the 
edge  of  the  weapon  have  passed  under  the  scalp  for  any 
distance,  it  is  important  to  ascertain  the  condition  of 
the  whole  wound,  the  absence  or  presence  of  foreign 
bodies,  or  organic  impurities,  before  the  edges  are 
adjusted.  If  it  should  prove  to  be  clean,  or  can  be 
rendered  clean,  it  should  be  at  once  closed  and  im- 
mediate union  hoped  for.  When  this  result  is 
unlikely  to  be  obtained,  it  is  better  not  to  be  too 
particular  in  bringing  the  edges  of  the  scalp  together, 
because  matter  is  apt  to  form  under  the  fiap,  and  if 
the  margin  be  too  quickly  united,  it  may  be  necessary, 
in  order  to  allow  of  its  escape,  to  separate  them,  or 
make  a  distinct  incision. 

The  most  usual  cause  of  incised  wounds  is,  of 
course,  a  sharp  cutting  edge,  but  sometimes  such  a 
wound  may  be  inflicted  with  a  blunt  or  fiat  instrument, 
especially  if  its  surface  be  smooth.  It  is  often  found 
that  wounds  produced  by  falls  on  the  ice,  in  skating, 
are  as  sharply  defined  and  cleanly  cut  as  if  done  by  a 
razor.  This  point  may  prove  to  be  of  medico-legal 
importance. 

Aaiother  form  of  incised  wound  which  possesses 
z— 21 


386  Manual  of  S'jncr.KY. 

special  importance  from  its  sequences  is  the  incision 
made  in  removinfj  the  ordinary  sebaceous  tumour  or 
wen  from  the  scalp,  respecting  which  there  is  a 
common  belief  that  it  is  especially  liable  to  be  followed 
by  erysipelas,  I  believe  that  before  the  period  of  anti- 
septic surgery  this  opinion  was  well  grounded,  but  of 
late  the  precautions  adopted  have  rendered  this 
operation  as  safe,  practically,  as  any  other  of  a  like 
gravity. 

Contused  u'oi'.nds  are  serious  in  proportion  to 
their  extent,  position,  and  the  amount  of  injury  to 
the  soft  pai-ts.  It  is  hardly  possible  to  secure  their 
immediate  union,  and  as  the  edges  of  the  wound  must 
be  expected  to  become  rounded  otf  by  limited  sloughing, 
it  is  unnecessary  to  apply  adhesive  plaisters  or  other 
means  of  retention  until  the  edges  have  begun  to 
gi'anulate.  These  woimds  and  the  next  variety  are 
usually  unattended  by  haemorrhage. 

Lacerated  icoirnds  are  perhaps  the  most  common 
of  scalp  injuries,  varying  in  extent  from  a  slight  tear 
through  the  soft  structures  to  the  more  severe  foiTus 
included  under  the  head  of  flap  wounds.  Lacerated 
wounds,  ha^^Ilg  been  washed  and  cleansed,  must  be 
treated  as  the  last  variety,  bearing  in  mind  that,  in 
addition  to  the  common  inflammatory  complications, 
tetanus  is  an  occasional  result. 

Flap  wounds. — In  civil  practice  these  are  gene- 
rally met  with  as  machinery  accidents,  the  passing 
over  the  head  of  a  car  wheel,  or  a  fall  from  a  vehicle 
in  motion.  In  military  practice  they  are  produced 
by  all  kinds  of  ^•iolence  :  from  shot,  shell,  sabre,  or 
hoof  of  horse,  and  they  vary  in  extent  from  a  slight 
separation  of  the  scalp  to  a  tearing  away  of  almost  the 
whole.  Tlie  dangers  of  flap  wounds  are  those  of  con- 
tused and  lacerated  wounds  in  general,  haemorrhage 
being  seldom  present. 

Treatment. — Cut  the  hair  close  or  shave  the  flap 


Wounds  of  the  Scalp.  387 

and  the  adjacent  portion  of  the  scalp,  cleansmg  care- 
fully the  deep  surface,  removing  all  foreign  bodies, 
such  as  gravel,  earth,  dust,  etc.  This  can  best  be 
done  by  directing  a  stream  of  carbolised  tepid  water 
(1  in  80)  on  the  torn  part;  but  the  cleansing  process 
must  not  be  carried  on  too  long,  lest  the  vitality  of 
the  flap  be  lowered,  and  because,  in  most  cases,  except 
those  in  which  antiseptic  treatment  can  be  at  once 
adopted,  a  good  deal  of  suppuration  is  inevitable,  and 
by  tills  the  foreign  bodies  will  be  carried  away.  No 
matter  how  small  may  be  the  bridge  of  scalp  connecting 
the  detached  portion  with  the  adjacent  uninjured 
structure,  an  attempt  should  be  made  to  save  the 
flap,  remembering  the  rule  that  the  scalp  has  no 
tendency  to  slough.  To  retain  it  in  position,  sutures, 
plaisters,  the  four-tailed  bandage,  or  the  double-headed 
roller  (the  capeline)  may  be  used ;  and  it  is  well  to 
bear  in  mind  that,  ancient  prejudice  notwithstanding, 
there  is  no  objection  to  sutures  in  the  scalp,  their 
presence  there  being  as  unlikely  to  produce  untoward 
consequences  as  in  any  other  region.  Judicious 
pressure  by  pad  and  bandage  over  the  flap  tends  to 
avert  the  danger  of  deep-seated  suppuration,  and  the 
too  hasty  union  of  the  edges  should  not  be  sought  for 
whilst  there  is  any  probability  of  this  occurrence. 
In  the  event  of  the  flap  being  wholly  torn  ofi"  or 
dying,  notwithstanding  all  these  precautions,  a  clean 
cut  surface  will  be  left  to  heal  by  granulation,  while 
the  pericranium,  or,  even  when  that  is  injured,  the 
bone  itself,  will,  in  a  short  time,  present  a  few  pink 
granulations,  which  will  increase  rapidly  and  coalesce, 
until  the  whole  surface  is  covered  by  healthy  granula- 
tion tissue,  and  cicatrisation  will  follow.  The  treat- 
ment then  should  be  of  the  simplest  kind,  water 
dressings  and  cleanliness  being  the  chief  agents ;  but 
these  are  not  to  be  persevered  in  too  long  lest  they 
produce  a  "  soddening "  eflect,  and  a  surface  of  the 


388  Manual  of  Surgery. 

nature  of  a  weak  ulcer,  with  large,  pale,  flabby, 
granulations,  be  the  result.  At  this  time  the  healing 
may  be  very  much  accelerated  by  the  judicious 
employment  of  skin  grafting,  as  there  is  no  surface  on 
which  the  grafts  are  more  prone  to  "  take"  and  their 
constituents  to  proliferate.  It  must  be  borne  in  mind 
that  any  method  of  cicatrisation  eventually  tends  to  a 
certain  tightness  and  immobility,  which  may  be  pro- 
ductive of  deformity  whenever  it  is  extensive,  especially 
when  the  scar  is  situated  in  the  frontal  region. 

Punctured  wounds.  —  These  wounds  are,  as  a 
rule,  looked  upon  with  more  suspicion  than  any 
others,  not  only  from  the  greater  likelihood  of  their 
being  attended  with  injury  of  the  skull  or  its  contents, 
but  because  they  are  frequently  followed  by  deep- 
seated  inflammation.  These  wounds  are  caused  by 
stabs  of  pointed  instruments,  blows  of  sharp  stones, 
falls  against  projecting  angles,  etc.,  and  as  they  are 
sometimes  small  they  may  be  overlooked^  especially 
if  the  hair  be  thick,  and  as  they  are  usually  un- 
attended with  much  haemorrhage. 

Treatment. — The  adjacent  scalp  should  be  shaved, 
and  the  wounds,  if  seen  in  time,  dressed  antiseptically, 
first  having  made  a  full  exploration  with  probe  or  the 
little  finger.  If  some  hours  have  elapsed  a  linseed 
meal  or  bread  and  water  poultice  should  be  applied, 
and  complications  treated  if  tliey  arise. 

Poisoned  wounds  and  gun-sliot  loounds  of  the 
scalp  require  no  especial  notice.  {See  Arts,  xxxii. 
and  XV.,  vol.  i.) 

Deep-Sealed  iiiflauiuiatiou  of  the  scalp.— 
Besides  the  dangers  of  superficial  erysipelatous  inflam- 
mation, suppuration,  pyaemia,  and  tetanus,  which 
may  follow  upon  scalp  wounds  as  well  as  those  in 
other  parts,  there  is  a  peculiar  form  of  inflammation 
which  usually  presents  special  features,  and  may  be 
designated    by   this    name.       This    inflammation    is 


Inflammation  of  the  Scalp.  •589 

probably  erysipelatous  in  its  character.  Some  two  or 
three  days  after  the  reception  of  a  scalp  wound, 
which  lip  to  this  period  has  been  going  on  well,  the 
surgeon  observes  a  local  change,  a  red.  blush  surrounds 
the  wound,  its  edges  become  swollen,  everted,  and 
tender,  the  surfaces  very  dry  and  painful,  and  the 
cervical  glands  probably  enlarged.  In  the  course  of 
from  six  to  twenty -four  hours  nausea  supervenes,  and 
sometimes  vomiting  and  rigors  occur,  while  the  pulse 
and  temperature  at  once  mount  up  and  the  local 
changes  become  striking.  In  the  milder  cases  the 
swelling  gradually  subsides  without  suppuration, 
except,  i^erhaps,  immediately  adjoining  the  wound. 
In  the  graver  cases,  on  the  other  hand,  the  swelling 
is  rapid,  is  marked  by  a  dusky  uniform  redness,  and 
soon  presents  a  "  boggy "  feel,  indicating  diffused 
suppuration,  and  a  somewhat  emphysematous  crack- 
ling is  felt,  which  denotes  sloughing  of  the  areolar 
tissue.  The  dusky  swelling  may  increase  to  an  extra- 
ordinary extent,  the  head  appearing  nearly  double 
its  natural  size  ;  and  as  the  suppurating  and  sloughing 
process  extend  along  the  deep  plane  of  areolar  tissue 
in  the  direction  of  least  resistance,  the  eyelids  swell 
enormously,  the  eyes  close,  and  the  nose  becomes 
monstrous.  Deposits  of  matter  in  the  sloughy  areolar 
tissue  form  in  the  eyelids  and  near  the  ears,  whilst  the 
two  anterior  fleshy  portions  of  the  occipito-frontalis 
muscle,  being  less  resistant  than  the  epicranial 
aiioneurosis,  stand  prominently  forward  as  two  semi- 
circular tumours  on  the  forehead,  soon,  however, 
becoming  merged  in  the  general  swelling. 

Constitutional  signs,  at  first  those  of  irritative 
fever,  change  after  a  short  time  to  surgical  tyi)hoid, 
and  thereupon  the  tongue  becomes  dry  and  brown, 
muttering  delirium  sets  in,  and  general  depression 
of  the  vital  powers  follows. 

The  treatment  of  this  variety  consists   mainly  in 


390  Manual  of  Surgery, 

early  and  free  incisions,  allowing  matter  and  gan- 
grenous areolar  tissue  to  escape  in  every  direction  where 
they  may  present.  Tonics  and  support  will  be  in- 
dicated from  an  early  period,  and  under  this  treat- 
ment even  the  worst  cases  of  the  disease  may  recover 
with  no  greater  inconvenience  than  a  tight  or  im- 
movable scalp.     {See  also  Art.  vii.,  page  365.) 

Contusions  and  Inflammation  of  the  Skull. 

The  relations  between  periosteum  and  bone,  so 
intimate  throughout  the  entire  skeleton,  that  injury 
or  disease  of  either  cannot  always  be  differentiated, 
are  well  marked  in  the  skull,  although,  from  the 
copious  vascular  channels  of  the  diploe,  the  os- 
seous structure  is  not  so  dependent  on  the  investing 
membrane  as  in  other  regions. 

lujui'ics  of  the  pericranium  may  be  trivial 
or  grave,  according  to  the  amount  of  the  original 
violence,  and  the  extent  of  the  exposure  of  surface 
to  atmospheric  contact.  The  symptoms  will  vary 
proportionately  from  those  of  slight  periosteal  injury, 
with  pain,  tenderness,  and  swelling,  to  extensive 
periostitis  with  its  complications  and  sequelae.  The 
symptoms  of  serious  inflammation  of  the  pericranium 
resemble,  as  in  other  situations,  those  of  erysipelas, 
or  of  deep-seated  inflammation  of  the  scalp.  A  blow 
on  the  head,  followed,  after  an  interval  of  from  one 
to  three  days,  by  localised  swelling  with  pain  of  a 
severe  character,  and  accompanied  or  j^receded  by 
nausea  or  vomiting,  chills,  increase  of  temperature, 
and  other  febrile  phenomena,  may  indicate  either  of 
these  two  morbid  conditions.  If,  however,  the 
physical  signs  remain  localised  over  a  particular  part 
of  the  skull,  and  are  persistent  beyond  the  ordinary 
duration  of  scalp  inflammations,  if  the  pain  also  become 
more  intense,  unaccompanied,  of  course,  by  intra- 
cranial symptoms,  periostitis  may  be  suspected. 


Cranial  Osteitis.  391 

Cranial  periostitis,  like  the  same  condition 
elsewhere,  may  end  in  (a)  resolution ;  (6)  chronic  peri- 
ostitis ;  (c)  suppuration  ;  {d)  disease  of  the  subjacent 
bone.  In  the  first  case  the  symptoms  gradually  subside. 
and  the  localised  swelling  slowly  disappears,  while  in 
the  second  case  chronic  thickening  of  the  periosteum 
(a  node)  is  likely  to  be  the  result.  The  treatment  for  both 
should  be  on  the  general  principles  laid  down  in  the 
article  on  Diseases  of  the  Bones.  If  in  the  course 
of  the  disease  an  exacerbation  with  rigors  should  occur, 
accompanied  by  local  pitting  or  obscure  fluctuation, 
subpericranial  matter  may  be  diagnosed,  and  free 
incisions  should  be  resorted  to,  because  here,  as  in 
other  regions,  the  contact  of  pus  may  impair  the 
vitality  of  the  bone.  It  need  hardly  be  said  that 
antiseptic  precautions,  valuable  in  all  cases,  are  here 
of  paramount  importance.  Complete  separation  of 
the  pericranium  from  the  bone,  whether  the  result  of 
the  original  wound  or  of  subsequent  suppuration,  may 
probably  lead  to  exfoliation  or  to  complete  necrosis, 
but  this  effect  does  not  necessarily  follow. 

Contusion  of  tlie  cranial  bones,  which 
must  necessarily  involve  the  pericranium,  present  the 
same  symptoms  at  first  as  periosteal  inflammation. 
Contusion  of  the  skull  frequently  occurs  as  the  result 
of  blows  or  falls,  without  producing  any  results 
beyond  trivial  inflammatory  symptoms,  local  and 
general,  of  a  more  or  less  transient  character.  There 
is  always  a  danger  of  more  serious  bone  trouble, 
especially  if  the  injury  be  compound,  for  then  it  will 
be  attended  with  all  the  usual  risks  of  septic  infec- 
tion. Cranial  injuries  are  particularly  predisposed  to 
such  infection  by  reason  of  the  abundant  supply 
of  large  diploic  veins,  which  remain  patent  in  con- 
sequence of  their  connections. 

Osteitis,  the  result  of  injuries  of  the  skull,  pre- 
sents   the   usual    localised    inflammatory   symptoms, 


392  Manual  of  Surgery. 

varied  according:  to  their  nature  and  extent.  In  the 
less  serious  forms  the  results  are  tliickening  and  indura- 
tion ;  wliile  in  the  graver  varieties  death  of  the  bone, 
osteo-phlebitis,  with  its  consequences,  septicaemia  and 
pysemia,  extension  of  the  disease  to  the  dura  mater, 
or  a  combination  of  all  these  conditions  may  follow. 
Should  a  wound  be  present,  the  occurrence  of  sub- 
pericranial  suppuration  can  be  diagnosed,  and  exit  to 
the  matter  should  be  at  once  given,  and  if,  on  exami-  - 
nation,  the  bone  be  found  to  be  bare  and  dead,  a 
subsequent  exfoliation  may  be  expected.  The  -occur- 
rence of  repeated  rigors  points  to  osteo-jMehitis  and 
fycemia  (Hutchinson),  each  rigor  indicating,  prob- 
ably, a  new  focus  of  purulent  infection  in  some 
distant  organ.  The  occurrence  of  pneumonic  symp- 
toms, jaundice,  multiple  peripheral  abscesses,  or 
arthritic  suppuration,  indicate  successively  the  locality 
of  these  foci  before  post-mortem  examination  demon- 
strates them.  If  these  general  evidences  of  pysemic 
infection  be  present,  it  is  not  likely  that  operative 
interference  with  the  bone  will  be  of  much  benefit ;  but 
if  the  symptoms  point  rather  to  the  implication  of 
the  immediately  subjacent  dura  mater,  with  signs  of 
localised  cerebral  irritation  or  compression,  the  use  of 
the  trephine  is  justifiable. 

A  sign  which  is  generally  acknowledged  to  be 
very  rare,  and  which  is  known  as  Pottos  imffy  tumou,r^ 
may  be  observed  to  follow  upon  injuries  of  the  head. 
It  appears  as  a  tender,  circumscribed,  flattened 
swelling,  and  it  indicates  the  formation  of  matter 
between  the  bone  and  dura  mater,  for  which  condition 
incision  or  trephining  may  be  immediately  necessary. 

I>i<rei*cntial  dia^^iiosis  of  cranial  iiiflam- 
matioia.  —  What  symptoms,  then,  differentiate  [a) 
simple  cranial  necrosis,  (6)  osteo-phlebitis,  and  (c) 
the  extension  of  the  inflammation  to  the  intra- 
cranial    structures  ?      The    first,    simple    necrosis,    is 


Fractures  cf  the   Skull.  393 

indicated  by  local  tenderness,  local  suppuration, 
denudation  of  the  bone,  with  comparatively  trivial 
constitutional  symptoms,  slow  in  progi'ess,  followed 
by  necrosis,  exfoliation,  or  recovering  of  the  bone 
by  a  process  of  gi'anulation.  If,  in  addition, 
recun-ent  rigors  occur,  with  high  temperature,  sweat- 
ings, quick  and  feeble  pulse,  chest  or  abdominal 
symptoms,  or  swollen  joints,  the  second  condition, 
osteo-phlebitis,  may  be  diagnosed.  If  the  fever 
has  increased,  with  headache,  delirium,  toi*por,  and 
more  or  less  paralysis,  the  third  condition,  extension 
to  the  intracranial  structures,  has  occurred,  and  may 
be  followed  by  convulsions,  coma,  and  death.  The 
colour  of  the  bone,  when  dead,  is  a  peculiar  greenish 
white,  and  it  must  be  remembered  that  injuries 
causing  the  necrosis,  even  osteo-phlebitis  and  its 
consequences,  may  vary  from  a  simple  exposure  of 
lacerated  pericranium  to  the  contusion  just  described, 
or  to  any  of  the  varieties  of  fracture. 

Fractures  of  the  Skull. 

A  short  classification  of  the  fi^actures  of  the  skull 
is  necessary  to  a  proper  understanding  of  the  compli- 
cations respectively  attending  them. 

Classification. — Fractures  may  be  divided  into  : 

1 .  Partial,  implicating  one  or  other  table  of  the  skull. 

2.  Complete,  invohing  the  entire  thickness  of  the 
skull  case.  The  first  may  be  subdivided  into  (1) 
fracture  of  the  outer  table  alone,  such  as  occurs  over 
the  frontal  sinuses  or  mastoid  cells ;  (2)  fracture 
laying  open  the  dipliie  ("scratch"  fracture  of  Hutch- 
inson) ;  (3)  fi'acture  of  the  inner  table  alone. 

The  second  class  comprises  (1)  fissure;  (2)  com- 
minuted, stellate,  or  radiate  fracture ;  (3)  punctured 
fracture  ;  (4)  fracture  of  the  base  ;  (5)  compound  ;  and 
(6)  depressed  fracture.  In  addition  to  the  above,  a 
disputed  lesion,  the  existence  of  which  is  doubted,  but 


394  Manual  of  Surgery. 

which  has  been  described  as  (7)  fracture  by  contre  coup, 
should  be  mentioned.  The  word  compound,  aa 
applied  to  fractures,  has  the  same  meaning  here  as 
in  other  regions. 

Oeneral  characters. — It  is  well  worth  remark- 
ing, as  Kancrede  has  done,  "  that  a  fracture  of  the  skull 
has  no  inherent  danger  over  and  above  similar 
injuries  of  other  bones,  indeed,  not  nearly  as  much, 
if  we  accept  the  peculiar  arrangement  of  its  diploic 
venous  channels  which  predispose  to  purulent  infec- 
tion. I  repeat  again,  a  fracture  of  the  skull,  per  se, 
is  not  a  dangerous  injury ;  and  I  thus  reiterate  the 
statement  in  order  to  point  out .  the  error  too  often 
made  of  concentrating  attention  upon  the  fracture 
instead  of  upon  the  concomitant  cerebral  injuries, 
and  because  so  much  has  been  written  concerning  the 
risk  of  converting  a  simple  into  a  compound  fracture 
by  incising  the  integuments,  when  the  former  pre- 
sents symptoms  of  cerebral  compression,  forgetting 
that,  though  making  a  fracture  of  the  thigh  com- 
pound directly  imperils  the  patient's  life,  the  course 
of  the  injury,  as  far  as  life  is  concerned,  differs  little 
in  compound  and  simple  fractures  of  the  skull,  pro- 
vided that  intracranial  inflammation  can  be  avoided. 
I  do  not  deny  that  intracranial  complications  may 
be  aggravated  by  a  reckless  admission  of  air  to  a 
previously  simple  cranial  fracture  ;  but  I  deny  that 
with  modern  antiseptic  precautions  the  danger  of  the 
operation  is  to  be  compared  to  the  risks  of  intra- 
cranial inflammation  from  the  irritation  of  depressed 
fragments  of  bone,  and  that  any  comparison  can  be 
justly  drawn  between  a  compound  fracture  of  a  long 
bone  and  one  of  the  skull." 

Fractures,  other  than  simple  fissures  of  the  cranial 
bones,  usually  display  a  much  greater  injury  and  dis- 
placement of  the  inner  table  than  of  the  outer. 

"  For   the    explanation    of    this     fact  there    are 


Fractures  of  the  Skull.  395 

three  factors :  first,  its  physical  structure  being  the 
more  brittle  of  the  two  ;  second,  the  operation  of  a 
law  which  determines  a  fracture  first  on  the  side  of 
greatest  extension,  or,  as  iron-masters  express  it,  on 
the  '  side  of  pull ; '  and  ^third,  the  mass  of  material 
carried  before  the  fracturing  force.  The  law  which 
determines  a  fracture  of  the  skull  is  the  same  by  what- 
ever kind  of  force  it  is  produced.  The  fibres  of  the 
bone  yield  first,  as  has  been  stated,  on  the  side  of 
extension,  just  as  when  a  stick  is  bent  over  the  knee 
the  surface  opposite  to  the  point  where  the  pressure 
is  applied  first  gives  way.  The  application  of  the  law 
has  been  well  illustrated  by  Tee  van." 

Partial  fracture,  implicating  the  frontal 
sinuses,  may  be  accompanied  by  emphysema  of  the 
scalp,  and  with  epistaxis,  or,  if  it  be  compound,  its 
existence  may  be  shown  by  the  patient  being  able  to 
force  the  air  from  his  nose  through  the  wound. 

Scratch  fracture  corresponds  very  closely  to 
the  contusion  already  described,  and  in  certain  cases 
we  occasionally  find  the  external  table  scratched  by 
direct  attrition  upon  some  liard  substance.  Now  and 
then  tliese  scratches  are  so  suj)erficial  that,  being 
exactly  limited  in  length  to  the  part  actually  touched 
by  the  substance  causing  the  injury,  they  scarcely 
deserve  the  name  of  fracture.  Their  existence,  how- 
ever, always  proves  severe  contusion  of  the  bone, 
and  sometimes  it  is  very  difiicult  to  distinguish  between 
a  scratch  and  a  linear  fracture  especially.  They  some- 
times involve  more  than  a  scratch,  the  outer  surface 
of  the  bone  being  ploughed  up  over  a  considerable 
extent,  still  without  any  fissuring  (Hutchinson). 

A  fracture  of  the  internal  table  may  occur, 
and  the  external  remain  whole  ;  and  examples  of  this 
kind  are  given  by  Sir  Astley  Cooper,  Yelpeau, 
Adams,  Brodie,  Agnew,  and  others.  In  a  patient 
whom  Agnew  trephined    for  traumatic  epilepsy,  the 


396 


Manual  of  Surgery. 


inner  table  was  found  fractured  and  depressed  without 
any  break  whatever  in  the  outer  lamina. 

These  cases  can  only  be  positively  ascertained  by 
such  operation  or  by  post-mortem  examination. 

Simple  fissure,  like  a  crack  in  a  pane  of  glass, 
may  be  productive  of  no  further  symptom  than  that 
caused  by  shock  of  injury,  and  no  doubt  its  existence 
is  often  undiscovered.  Its  presence  is  frequently 
demonstrated  when  the  condition  of  the  bone,  or  of  the 
intracranial  structures,  renders  incision  or  exploration 
necessary,  or  else  on  j^ost-mortem  examination. 

No  operative  interference  is  indicated  unless  death 
of  the  bone  with  intracranial  suppuration  should 
produce  dangerous  symptoms. 

Coiniiiiiiittecl,  stellate,  or  radiate  fractures 
are  those  in  which  a  portion  of  the  skull  case  is  broken 

into  several  pieces,  the 
line  of  fracture  some- 
times diverging  from  a 
point,  or  a  circular  frag- 
ment, in  which  case  the 
words  stellate  or  radiate 
sufficiently  indicate  the 
characters  of  the  injury 
If  the  stellate  fracture  be 
depressed  the  bone  yields 
circumferentially,  and  a 
fissure  circumscribes  the 
radiating  lines,  which  slope  down  to  the  place  of 
greatest  depression. 

This  has  been  termed  by  Hutchinson  the  "  ;;o??(:^  " 
fracture^  the  lines  of  which,  in  some  cases,  converge 
to  a  point  as  to  a  centre,  and  in  others  to  a  small 
circle  of  depressed  bone  like  the  ''  hub  "  of  a  wheel 
(Fig.  85).  If  it  be  com]iound,  immediate  elevation  of 
the  bone  becomes  necessary,  and  persistence  of  symp- 
toms  may   force  the   adoption  of  similar   treatment 


Fig.85.— PoudFractureoftheSkuU. 


Fractures  of  the  Skull. 


39: 


"when  the  fracture  is  only  simple.  Although  in  some 
cases  the  fragments  are  very  movable,  in  others 
they  are  locked  together  so  forcibly  that  the  trephine 
may  be  required  to  remove  a  piece  of  the  cranium 
outside  the  circumferential  lissiu'e,  and  it  may  be  even 
necessary  to  detach  altogether  one  of  the  depressed 
and  locked  "  sectors  "  before  the  others  can  be  raised 
to  the  normal  level.  "  Gutter^''  fracture  is,  in  principle, 
the  same  as  pond  fracture,  but  its  shape  is  elliptical, 
and  the  greatest  depression 
corresponds  to  a  line  in  the 
long  axis  of  the  ellipse, 
towards  wliich  two  sur- 
faces of  bone  lead  down 
from  the  fracture  circum- 
scribing the  figure.  If  it 
be  compound,  which  is 
more  than  likely,  imme- 
diate surgical  interference 
is  indicated  (Fig.  86). 

Punctured  fracture 
is  one  of  the  most  serious 

and  important  to  the  surgeon.  It  is  produced  by  a 
sharp  point,  such  as  a  knife,  dagger,  scissors,  reaping 
hook,  or  pitchfork,  and  it  varies  in  size,  complications, 
and  dangers.  Immediate  cerebral  symptoms  may  be 
absolutely  wanting,  even  though  tlie  instrument  that 
caused  the  injury  be  embedded  in  the  brain.  Fractures 
through  the  roof  of  the  orbits  or  nose  frequently 
belong  to  this  variety,  and  may  sometimes  be  deficient 
in  any  symptoms  for  some  days,  though  in  other  cases 
they  prove  immediately  fatal. 

If  the  perforating  instrument  be  present  and  be 
detected,  it  must  be  removed  at  once,  and  if  the  situ- 
ation of  the  fracture  be  in  the  vault  of  the  skull,  the 
case  is  one  for  immediate  tre|)hining,  as  it  may  be  in- 
feri-ed  that  the  inner  table  of  the  bone  is  comminuted. 


Fi£ 


83. — Glitter  Fractiue  of  the 
SkuU. 


398  Manual  of  Surgery. 

and  that  spiculse  are  pressing  on  the  meninges,  or  on 
the  brain  substance. 

Fractures  of  the  base  of  the  skull  may    be 

divided  into  two  classes  :  (1)  Those  involving  only 
the  anterior  fossoe  of  the  cranium,  the  roof  of  the 
orbits,  or  nasal  cavity  ;  originating  therein,  or  travel- 
ling from  the  frontal  region.  (2)  Those  implicating 
the  true  base,  or  middle  cranial  and  occipital  fossae, 
which  fractures  usually  originate  from  below,  or  from 
the  extension  of  a  fissure  from  the  vault. 

1.  Injuries  of  the  first  of  these  classes  are  pro- 
duced by  blows  or  falls  on  the  forehead,  but  more  fre- 
quently by  perforating  instruments  passing  through 
the  nasal  or  orbital  ca\dties ;  a.nd  these  lesions  do  not 
necessarily  imply  any  marked  degree  of  violence, 
especially  in  the  punctured  wounds  of  the  orbits  or 
nose,  because  in  their  situation  the  bony  plates  are 
thin  and  fragile;  consequently  urgent  symptoms  may 
not  be  present.  The  treatment  of  such  cases  must  be 
guided  by  the  circumstances,  and  should  be  in  accord- 
ance with  the  rules  already  laid  down  for  punctured 
fracture. 

2.  In  the  second  variety  the  symptoms  are, 
as  a  rule,  so  well  defined  that  a  separate  description 
of  them  is  necessary.  These  fractures  usually  arise 
from  forces  acting  from  below,  such  as  a  fall  on  the 
feet  from  a  height.  Also  from  forces  applied  from 
above,  such  as  falls  or  severe  blows  on  the  cranial 
vault,  in  which  cases  the  fracture  most  commonly 
commences  at  the  part  struck,  and  travels  downwards 
into  the  base.  In  the  simplest  cases  a  fissure  runs 
through  the  petrous  portion  of  the  temporal  bone, 
involving  the  middle  ear,  and  sometimes  rupturing 
the  membrana  tympani  ;  but  in  more  severe  injuries 
the  occipital  bone  where  it  abuts  on  the  temporal  is  im- 
plicated, and  the  fissure  may  run  backwards  into  the  fora- 
men magnum  or  transversely  across  the  basilar  process 


Fractures  of  the  Skull.  399 

This  form  of  fracture  frequently  extends  com- 
pletely across  the  base  of  the  skull,  involving  the 
l)etrous  bone  and  the  tympanum  of  the  opposite  side, 
and  thus  separating  the  base  into  halves,  anterior  and 
posterior.  More  commonly  the  line  of  fracture  travels 
from  the  petrous  bone,  across  the  middle  fossa  and 
great  wing  of  sphenoid  to  the  roof  of  the  orbit,  or 
passing  through  the  body  of  the  sphenoid  involves  the 
cribriform  plate  of  the  ethmoid  and  roof  of  the  nose. 
In  still  more  serious  cases  all  these  lines  of  fracture 
may  co-exist,  the  foramen  magnum  being  extensively 
broken,  and  the  summit  of  the  vertebral  column  pro- 
jected into  the  cranial  cavity. 

Tlie  condyles  of  the  lower  jaw  may  be  driven 
by  violence  through  the  glenoid  cavity,  and  thus 
produce  a  fracture  of  the  base. 

In  an  accident  which  presents  so  many  varieties  and 
degrees  of  local  injury,  the  syiriftoms  may  be  naturally 
expected  to  vary  in  intensity.  In  addition  to  those  of 
concussion  and  compression,  hereafter  to  be  described, 
there  are  some  symptoms  peculiar  to  the  accident, 
and  indicative  of  the  particular  localities  affected ;  thus, 
bleeding  from  the  ear  or  ears,  welling  from  the  same 
cavities  of  a  clear  serum,  the  cerebro-spinal  fluid,  and 
deafness,  point  to  the  fissure  through  the  petrous  bone. 
Subconjunctival  ecchymosis  or  chemosis  of  clear  fluid 
shows  the  implication  of  the  roof  of  the  orbit.  Bleed- 
ing from  the  nose,  with  an  escape  of  serous  fluid,  may 
occur,  from  which  it  may  be  judged  that  the  roof  of 
that  cavity  is  fissured,  and  a  post-pharyngeal  bloody 
tumour  may  result  from  the  fracture  across  the  basilar 
process.  Several  of  the  cerebral  nerves  may  be  impli- 
cated by  the  accident ;  but  as  there  is  generally  pro- 
found coma  present,  little  direct  information  as  to 
their  functional  disturbance  is  available. 

The  prognosis  is  generally  fatal,  but  not  neces- 
sarily so.     Patients  presenting  symptoms   considered 


4O0  Manual  of  Surgery. 

pathognomic  of  the  accident,  have  been  known  to 
recover.  It  may  be  true  that  such  symptoms  occur 
irrespective  of  the  basic  fracture ;  but,  on  the  other 
hand,  it  has  been  found  by  subsequent  post-mortem 
examination  that  in  the  great  majority  of  cases  they 
have  this  origin.  It  is,  therefore,  more  than  probable, 
that  when  patients  exhibit  such  symptoms,  and  do 
not  die,  the  result  proves  only  that  the  slighter 
forms  of  the  accident  are  not  always  fatal.  This 
hypothesis  is  confirmed  by  the  fact  that  there  are 
in  museums  well-marked  specimens  of  these  less  severe 
fractures,  obtained  at  remote  periods  after  the  patients 
have  presented  these  symptoms  and  recovered. 

From  the  foregoing  observations  it  will  be  seen  that 
any  treatment  directed  to  the  lesion  itself  is  out  of  the 
question. 

Fracture  by  coiitre  coup.  —  The  nature  and 
possibility  of  this  fracture  has  been  a  matter 
of  much  dispute.  If  it  be  held  that  it  is  a  yield- 
ing of  one  ])art  of  the  skull  produced  by  violence, 
applied  to  the  exactly  opposite  region,  the  occurrence 
of  the  precise  lesion  may  well  be  questioned ;  but 
there  is  no  doubt  that  in  severe  cranial  accidents 
caused  by  considerable  force,  fractures  do  occur  in 
other  parts  of  the  cranium  than  those  to  which  the 
force  is  applied.     Of  such  I  have  seen  examples. 

Separation  of  sutures. — These  accidents,  un- 
complicated by  fractures,  ax'e  extremely  rare.  In  two 
of  Hutchinson's  cases  they  are  complicated  with  frac- 
tures of  the  base  and  parietal  bone,  and  Hewitt  has  seen 
but  one  instance  of  such  separation  Avithout  fracture. 

Out  of  twenty -three  cases  the  coronal  suture  was  separ- 
ated in  seven,  the  lambdoid  in  six,  the  sagittal  in  four, 
the  petro-occipital  in  four,  the  temporo-parietal  in  one, 
and  the  splieno-parietal  in  one.  The  prognosis  of  such 
injuries  is  unfavourable,  because  the  violence  necessary 
to  produce  thQ  accident  must  be  extreme. 


Fractures  of  the  Skull,  401 

As  each,  separately,  is  likely  to  be  attended  with 
fracture  of  the  skull,  the  treatment  is  the  same  as  for 
that  injury. 

Depressed  fractiu'e. —  From  what  has  been 
said  as  to  the  want  of  special  gravity  of  fractures  of 
the  cranial  bones  j)er  se^  it  is  obvious  that  the  only 
fractures  important  to  be  recognised  as  such  are 
those  attended  with  depression  ;  and  with  these  also 
the  amount  of  depression  is  of  little  importance  in 
itself,  but  of  gi^eat  moment  with  reference  to  the  injury 
of  the  brain  or  membranes  which  it  may  involve. 
It  is  plain,  then,  that  so  far  as  fractures  of  the  skull 
require  surgical  interference,  the  depressed  fracture  is 
that  in  which  the  diagnosis  is  most  important.  The 
existence  of  depressed  fracture  is  not  always  easy  to 
ascertain ;  for  if  it  be  simple,  the  thickness  of  the  scalp, 
augmented  by  effused  blood  or  inflammatory  products, 
renders  the  recognition  difficult,  unless  the  depression 
be  very  great.  As,  however,  operative  interference  is 
not  indicated  here,  unless  other  symptoms  be  present, 
accurate  diagnosis  is  of  secondaiy  importance,  and  in 
cases  of  necessity  doubts  may  be  removed  by  an  ex- 
ploratory incision. 

The  existence  of  compound  depressed  fracture  can 
be  ascertained  by  the  use  of  the  probe  or  finger  nail  ; 
but  even  here  an  unevenness  of  the  bones,  or  tlie 
presence  of  a  cranial  suture  in  the  wound,  may  render 
a  mistake  possible. 

Depression  of  the  cranial  bones  may  exist  without 
fracture.  Tliis  occurs  in  children  while  the  bones  are 
soft,  and  may  exist  to  a  considerable  degree  (Erichsen). 

Concussion,   Contusion,   Laceration,   and   Com- 
pression OF  THE  Brain. 

Since  fractures   of  the   cranial  bones    do  not,  as 
has  been  already  remarked,  present  in  themselves  any 
special  dangers,  save  those  which  the  existence  of  large 
A  A— 21 


402  Manual  of  Surgery. 

patulous  veins  predispose  to,  it  is  necessary  to  consider 
very  fully  the  conditions  of  the  brain  which  lend  pecu- 
liar gravity  to  injuries  of  the  head. 

CoiicMSSion  may  be  defined  as  a  shock  or  vibra- 
tion to  the  brain,  and  it  varies  in  amount  according  to 
the  intensity  of  the  cause.  The  transient  giddiness, 
flashes  of  light  before  the  eyes,  and  cerebral  derange- 
ment, which  are  perceived  when  the  head  is  struck  ac- 
cidentally against  a  low  doorway  in  the  dark,  repre- 
sent the  slightest  form  of  concussion,  beyond  which 
the  injury  presents  every  description  of  severity  to 
complete  insensibility  and  death. 

I  do  not  mean  to  define  concussion  as  a  shock  un- 
attended by  perceptible  lesions,  nor  is  it  necessary  to 
enter  into  the  question  as  to  whether  death  from  con- 
cussion^ unaccompanied  by  these  lesions,  is  possible. 
The  entire  anatomical  arrangements  connected  with  the 
brain,  its  vascular  supply,  its  serous  envelope,  its 
water-bed  of  subarachnoid  fluid,  all  are  meant  to  mini- 
mise the  effects  of  shock.  It  may  be,  as  Duret  main- 
tains, that  the  earlier  symptoms  of  concussion  are  due 
to  ansemia  from  spasm  of  the  muscular  coats  of  the 
arteries,  and  that  a  secondary  result  is  congestion  from 
paresis,  or  inflammatory  dilatation  of  the  same  vessels, 
and  with  this  latter  condition  disseminated  haemor- 
rhages may  be  associated,  whose  presence  as  irritants 
may  augment  the  tendency  to  local  congestion.  It 
will  simplify  the  matter  to  state  that  the  most  minute 
descriptions  which  have  been  given  represent  the  con- 
dition as  one  of  surgical  shock  with  the  additional  brain 
symptoms. 

It  is  usual  to  contrast  concussion  with  compres- 
sion, for  the  purpose  of  differential  diagnosis,  but  such 
distinction  it  is  not  always  possible  to  make,  especially 
just  after  the  accident,  because  an  injury  of  the 
head  sufficient  to  produce  compression,  or  other 
manifest  lesions  of  the  brain,  must  obviously,  at  the 


Co.ycussioN.  403 

same  time,  give  rise  to  concussion,  and  the  two  groups 
of  symptoms  must  at  first  be  present,  until  tLose  of 
concussion  pass  away,  and  leave  those  of  the  other 
conditions  uncomplicated  and  manifest. 

Concussion  is  generally  divided  into  three  stages. 

(1)  Collapse  or  insensibility;  (2)  reaction;  and 
(3)  inflammation. 

1.  The  evidences  indicative  of  the  first  stage  of  con- 
cussion will  usually  be  a  quick,  weak,  and  sometimes 
intermitting  pulse  ;  the  breathing  quiet,  faint,  or  sigh- 
ing ;  the  skin  surface  cold,  sometimes  covered  with  a 
clammy  perspiration.  The  sphincters  usually,  but  not 
always,  are  able  to  perform  their  functions,  and  the 
intellect  is  more  or  less  interfered  with.  Nevertheless, 
it  is  possible,  except  in  the  very  severe  cases,  to  rouse 
the  patient  by  addressing  him  in  a  loud  voice.  In 
addition  to  these  usual  symptoms,  the  follo^ving  signs 
are  also  sometimes  present :  On  making  the  patient 
sit  up  the  carotid  arteries  are  seen  to  throb  with  more 
than  usual  force,  and  the  ratio  between  frequency 
of  pulse  and  respiration  may  be  disturbed,  a  sign,  as 
!Mr.  CoUes  observes,  of  grave  import;  while  there  is 
also  in  many  cases  a  tendency  to  sleep. 

2.  Reactionary  signs  are  usually  ushered  in  by 
vomiting  (which  is  therefore  looked  upon  not  only  as  a 
valuable  diagnostic  symptom,  but  as  one  of  favourable 
signification),  and,  after  a  time  varying  from  minutes 
to  hours,  or  days,  the  patient's  full  intellectual  powers 
return.  This  second  stage  may  be  succeeded  by  con- 
valescence, but  in  other  cases  the  reaction  becomes 
excessive,  and  after  a  time  may  develop  into  intra- 
cranial inflammation,  a  sequence  which  is  most  likely 
to  occur  when  the  concussion  has  been  complicated  by 
some  injury  of  the  brain  or  its  membranes.  There  is 
no  doubt,  however,  that  death  may  take  place  in.  the 
first  stage  and  also  in  the  second,  although  post-mortem 
examination  may  not  show  proof  of  the  existence  of 


404  Manual  of  Surgery. 

true  inflammation  by  the  presence  of  its  usual  pro- 
ducts. 

3.  Inflammatory  symptoms  sometimes  appear  as 
soon  as  the  third  day,  whilst  in  other  cases  their 
advent  is  post23oned  to  the  twelfth  or  fifteenth. 

The  diagnosis  of  concussion,  as  usually  understood, 
that  is,  of  the  first  stage  above  described,  is  of  more 
scientific  than  practical  interest,  because  the  indica- 
tions for  treatment  are  chiefly  negative,  and  a  full 
recognition  of  the  condition  implies  an  abstention  from 
surgical  interference,  while  the  setting  in  of  reaction 
is  awaited  or  encouraged  by  the  mildest  measures. 
Perfect  rest  must  be  enjoined,  accompanied  by  the 
application  of  warmth  to  the  surface,  and  the 
administration  of  hot  drinks  or  mild  stimulants. 
It  must  not  be  forgotten  that  the  amount  and 
duration  of  application  of  these  external  remedies 
must  be  regulated  by  the  surgeon's  intelligence,  and 
not  by  the  patient's  blunted  sensations. 

Cerebral  irritation. — In  connection  with  con- 
cussion may  be  mentioned  the  condition  described  by 
Erichsen  as  cerebral  in  itation.  "The  bodily  symptoms 
are  as  follow  :  The  attitude  of  the  patient  is  most 
cliaracteristic ;  he  lies  on  one  side,  and  is  curled  up  in 
a  state  of  general  flexion.  The  body  is  bent  forward, 
the  knees  are  drawn  up  on  the  abdomen,  the  legs  bent, 
the  arms  flexed,  and  the  hands  drawn  in.  He  is 
restless,  and  often,  when  ii-ritated,  tosses  himself 
about.  But,  however  restless  he  may  be,  he  never 
stretches  himself  out,  nor  assumes  the  supine  posi- 
tion, but  invariably  maintains  an  attitude  of 
flexion.  The  eyelids  are  firmly  closed,  and  he  resists 
violently  every  efi'ort  made  to  open  them  ;  if  this  be 
efiected,  the  pupils  will  be  found  to  be  contracted.  The 
surface  is  pale  and  cool,  or  even  cold.  There  is  no 
heat  of  head.  The  pulse  is  small,  feeble,  and  slow, 
seldom   above    70.     The  sphincters  are   not  usually 


Cerebral  Irritation.  405 

affected,  and  the  jiatient  will  pass  urine  when  the 
bladder  requires  to  be  emptied  ;  there  may,  however, 
though  rarely,  be  retention.  The  mental  state  is 
equally  peculiar.  Irritability  of  mind  is  the  pre- 
vailing characteristic.  The  patient  is  unconscious, 
takes  no  heed  of  what  passes,  unless  called  to  in  a 
loud  tone  of  voice,  when  he  shows  signs  of  irritability 
of  temper,  or  frowns,  turns  away  hastily,  mutters 
indistinctly,  and  grinds  his  teeth.  It  appears  as  if 
the  temper,  as  much  as  or  more  than  the  intellect, 
were  affected  in  this  condition.  He  sleeps  without 
stertor. 

The  course  taken  by  these- symptoms  is  as  follows  : 
After  a  period  varying  from  one  week  to  three,  the 
pulse  improves  in  tone,  the  temperature  of  the  body 
increases,  the  tendency  to  flexion  subsides,  and  the 
patient  lies  stretched  out.  The  mental  state  also 
changes.  Irritability  gives  way  to  fatuity ;  there  is  less 
manifestation  of  temper,  but  more  weakness  of  mind. 
Recovery  is  slow,  but,  though  delayed,  may  at  length 
be  perfect,  although  in  these,  as  in  all  other  cases  of 
cerebral  disturbance^  ulterior  consequences  may  be 
manifested. 

The  symptoms  that  have  just  been  described  usually 
follow  blows  upon  the  temple  or  forehead,  and 
probably  in  many  cases  may  ai'ise  from,  or  are 
associated  with,  lacerations  of  the  cerebral  substance, 
more  especially  of  the  grey  mattor. 

Although  this  condition  is  familiar  to  every  surgeon, 
it  is  plainly  a  prolonged  variety  of  concussion,  and  I 
should  prefer  confining  the  use  of  the  word  "irritation" 
to  cases  in  which  the  disturbance  in  the  brain  is  in- 
dicated by  some  more  special  peripheral  symptoms. 

Concussion  may  terminate  fatally  without  re- 
actionary signs,  and  in  such  cases  more  or  less  con- 
tusion, laceration,  and  localised  congestions  will 
probably    be   revealed   by  post-mortem  examination. 


4o6  Manual  of  Surgery. 

Some  of  the  early  writers  have  held  that  death  may 
occur  without  manifest  intracranial  lesion,  a  view 
earnestly,  and  I  think  successfully,  combated  by  Sir 
Prescott  Hewitt. 

Cerebral  inflaiiiiiiatioii.  —  Inflammation  of 
the  brain  or  its  membranes  was  formerly  described  as 
the  third  stage  of  concussion,  but  in  some  cases  it 
may  arise  from  an  injury  in  which  the  ordinary  signs 
of  concussion  are  absent. 

TJie  S7/mptoms  of  cerebral  inflammation  may  well 
be  classified,  as  E-ussell  Reynolds  has  done,  into  (a) 
sensorial,  (6)  motorial,  and  (c)  mental.  At  a  varying 
period  after  the  injury  the  patient  complains  of 
headache,  and  intolerance  of  light.  The  face  is  flushed 
and  the  conjunctivae  injected.  He  is  restless  and  sleep- 
less, whilst  the  pulse  and  temperature  indicate  inflam- 
matory mischief.  The  tongue  is  moist  and  some- 
times thickly  coated,  and  nausea  may  be  present. 
Later  on,  the  headache  will  be  succeeded  by  delirium, 
and  local  spasm  or  paralysis  of  certain  groups  of 
muscles,  amounting  often  to  complete  hemiplegia, 
will  indicate  the  part  of  the  brain  afiected.  This 
delirium  will  often  pass  into  coma,  sometimes 
preceded  by  convulsions,  or  by  a  ^-iolent  rigor,  which 
symptom  is  of  value  as  an  indication  of  suppuration. 
In  the  comatose  condition  all  the  natural  functions 
are  suspended  ;  urine  is  involuntarily  voided,  whilst 
at  the  same  time  there  may  be  retention,  a  point  of 
practical  importance.  Control  o^er  the  sj^hincter  ani 
may  also  be  lost. 

Local  paralyses  are  indicated  by  dilated  pupil, 
stertor  in  breathing,  and  more  or  less  hemiplegia, 
and,  in  fact,  the  case  resolves  itself  into  one  of  com- 
pression, and  the  symptoms  may  be  due  to  in- 
flammations of  the  dura  mater,  of  the  arachnoid,  of 
the  subarachnoid  spaces,  or  of  the  cortical  brain 
substance  itself.     How  far  the  presence  of  the  earlier 


Cerebral  Inflammation.  407 

inflammatory  products,  such  as  serum  or  lymph,  can 
produce  compression  may  be  a  debatable  subject, 
but  there  is  no  doubt  tliat  the  presence  of  pus  can 
give  rise  to  pressure  effects  which  disappear  on  its 
removal. 

The  treatment  of  such  a  case  from  the  beginning 
must  be  conducted  on  general  principles.  Excessive 
reaction  is  to  be  kept  in  check  by  rest,  cold  to  the 
head,  and  purgation,  with  perhaps  leeching  or  bleeding, 
and,  as  soon  as  the  rise  in  temperature  and  other 
symptoms  point  to  the  advent  of  inflammation,  a  more 
strictly  antiphlogistic  treatment  must  be  carried  out, 
and  the  use  of  mercury  internally  offers  the  best 
hopes  of  staying  or  resolving  the  inflammation.  When 
symptoms  of  compression  supervene  the  propriety  of 
surgical  interference  must  be  at  once  considered.  If 
the  inflammation  have  followed  upon  depressed 
fracture,  its  onset  will  suggest  the  removal  of  the 
probable  cause,  but  should  the  signs  present  them- 
selves at  an  early  period,  so  that  they  may  be 
considered  due  to  meningitis  or  encephalitis,  with 
exudation  of  lymph  or  serum,  interference  is  useless. 
At  a  later  period,  when  there  are  reasonable  grounds 
for  concluding  that  the  pressure  is  caused  by  pus,  and 
when  trustworthy  indications  exist  as  to  its  site,  the 
surgeon  is  not  only  justified,  but  called  upon,  to  afford 
his  patient  a  chance  of  recovery  by  endeavouring  to 
remove  the  purulent  effusion. 

Contusion  of  the  brain. — There  are  few  cases 
of  fatal  injury  to  the  head  in  which  some  contusion  is 
not  discernible  ;  contusion  as  evidenced  by  extravasa- 
tion of  blood  into  the  brain  substance,  with  consequent 
damage  to  the  same.  When  the  skull  receives  a 
severe  blow  the  brain  may  exhibit  directly  at  the 
point  affected  a  contusion ;  but,  as  the  efiect  of  the 
injury  is  also  to  throw  the  brain  against  the  opposite 
side  of  the  vault,  it  is  very  common  indeed  to  find 


4oS  Manual  of  Surgery, 

the  cerebral  contusion  on  that  side.  But  during  the 
vibration  or  concussion  which  the  brain  receives, 
extravasations  at  various  other  points  occur,  either 
directly  as  the  result  of  the  shake,  or  subsequently, 
from  alterations  in  vascular  pressure  and  tension. 

We  accordingly  find  two  classes  of  brain  con- 
tusion ;  one  circumscribed,  either  as  a  single  portion  of 
brain  infiltrated  with  blood,  or  an  agglomeration  of 
similar  smaller  efiusions. 

In  the  second  variety,  extravasations  more  minute 
are  disseminated  on  the  surface  or  through  the  surface 
of  the  brain.  If  the  accident  has  preceded  death  by 
some  time  these  spots  may  be  found  in  process  of 
change,  and  the  colouring  matter  of  the  blood  may  stain 
the  brain  substance  for  some  distance.  In  the 
smaller  ones  absorption  may  have  commenced,  whilst 
in  the  larger  ones  softening  and  disintegration  may 
be  present,  and  a  ragged  irregular  surface  like  an 
ulcer  may  be  the  result.  In  most  cases  at  the  same 
time  extravasation  into  the  membranes  will  be  present, 
the  pia  mater  and  arachnoid  bemg  both  probably 
torn.  This  contusion  of  the  brain  occurs  more 
frequently  at  the  base  or  anterior  lobes  than  on  the 
upper  surface. 

As  regards  symptoms^  it  is  obvious  that  they 
must  be  intermingled  with  those  of  concussion  and 
compression,  probably  often  obscuring  the  difierential 
diagnosis  between  those  two  states.  It  has  been  said 
that  local  tonic  spasm,  extreme  restlessness,  constant 
tossing  about,  are  more  or  less  characteristic  of  con- 
tusion ;  but  from  what  has  been  said  it  is  plain  that, 
unless  the  injury  implicate  one  of  the  motor  areas, 
and  that  immediate  disturbances  of  the  group  of 
muscles  connected  with  that  area  exhibit  themselves, 
exact  diagnosis  must  be  extremely  difficult,  or,  as 
some  autliorities  consider,  impossible  (Hewitt).  Any 
direct  treatment,  consequently,  can  seldom  be  practised, 


Compression.  409 

the  principal  indication  being  to  prevent  the  occur- 
rence of  encephalitis  or  meningitis,  the  remote  e fleets 
being  acute  or  chronic  abscess. 

Laceration  of  tUe  brain  may  occur  in  the 
same  class  of  cases  that  cause  contusion,  and  I  have 
frequently  seen  the  first  form  of  contusion  accom- 
panied by  laceration.  It  may  also  occur  from  direct 
violence  with  depressed  fracture  or  foreign  body,  and 
may  be  attended  with,  in  some  of  these  cases,  escape 
and  loss  of  brain  substance.  A  considerable  quantity 
has  been  thus  lost  and  yet  recovery  known  to  follow. 

The  symptoms  of  these  accidents,  in  addition  to 
those  of  concussion  or  compression,  will  depend  on 
the  particular  pa);t  of  the  brain  injured,  and  probably 
vaiy  according  to  the  time  the  patient  may  survive. 

Other  Avounds  of  the  brain,  of  the  varieties  met 
in  other  regions  of  the  body,  are  described,  and 
range  from  the  slightest  puncture  to  considerable 
laceration  and  destruction,  but  they  need  no  detailed 
description ;  and  the  old  maxim  that  no  injuries  are 
too  grave  to  be  despaired  of  or  too  slight  to  be 
despised,  is  found  to  have  as  much  force  now  as 
when  it  was  uttered.  There  is  now  no  reason  to 
doubt  the  authenticity  of  Harlowe's  celebrated  case, 
where  a  crowbar  passed  through  the  side  of  the 
middle  fossa  of  the  cranium  from  below  and  emerged 
close  to  the  vertex,  the  patient  recovering  with  im- 
pairment of  intellect,  and  living  for  twelve  years  after. 

Compression. — Compression  from  inflammation 
having  been  described,  it  is  well  now  to  treat  of 
the  condition  in  general,  with  its  causes  and  its 
diflerential  diagnosis,  and  to  suggest  the  treatment 
suitable  to  the  various  cases.  Compression  may  arise 
from  either  injury  or  disease,  and  its  causes  may  be 
thus  enumerated  : 

Traumatic  causes. — Depressed  fracture,  pus,  seinira 
or  lymph,  foreign  body,  eflused  blood. 


41  o  Manual  of  Surgery. 

Tumours,  including  syphiloma,  carcinoma,  sarcoma, 
glioma,  scrofuloma,  osteoma,  angioma,  psammoma. 

SyiiiptoiiBS. — When  compression  is  the  result  of 
injury,  as  when  it  accompanies  depressed  fracture,  the 
symptoms  at  first  are  necessarily  mingled  with  those  of 
concussion.  The  extent  of  the  fracture  affords,  to 
some  extent,  a  measure  of  the  amount  of  violence 
used,  and  of  the  shake  to  the  brain  which  must  have 
resulted;  hut,  as  I  have  already  said,  it  will  not  be 
until  the  signs  of  concussion  pass  away,  that  those 
of  uncomplicated  compression  will  be  recognised. 
Sometimes,  even  then,  a  difficulty  of  diagnosis  will 
remain,  for,  in  the  reactionary  stage  of  concussion, 
symptoms  may  arise  which  it  is  difficult,  if  not  im- 
possible, to  distinguish  from  those  of  compression. 
Amongst  the  most  universally  acknowledged  signs 
are  :  Complete  insensibility  (coma) ;  full,  slow,  and 
labouring  pulse ;  stertorous  breathing,  and  in  the 
worst  cases  whiffing  respiration,  with  puffing  of  the 
cheeks.  The  skin  will  be  warm  and  sometimes 
flushed ;  the  pupils,  or  one  pupil,  usually  dilated  and 
insensible  to  light;  nausea  or  vomiting  absent;  bladder 
and  sphincter  paralysed ;  and  primary  hemiplegia 
more  or  less  marked. 

The  symptoms  of  the  two  states  in  parallel  columns 
are  quoted  here  from  Agnew,  with  slight  modifications. 

Concussion.  Compression. 

Unconsciousness  is  incomplete;  Complete      unconsciousness; 

patient  can  be  made  to  an-  may  scream  into  patient's 

swer,    though    it    may  be  ear  at  the  top  of  the  voice, 

briefly,  and  in  simple  words.  but  will  receive  no  answer. 

Special  senses,  though  greatly  Special   senses    entii'ely   suS' 

blunted,  are  not  abolished.  ponded. 

Power  of  movement  not  de-  Complete  or  partial  paralysis ; 

stroycd ;  if  the  position  of  in  most  cases  hemiplegia, 
a  limb  bo  changed  the  pa- 
tient will  resist  or  bring  it 
immediately  into  the  origi- 
nal position. 


Compression.  4 1 1 

Concussion.  Compression. 

Respiration  is  quiet  and  feeble.       Respiration  full  and  noisy. 
Pulse   feeble,    frequent,    and       Pulse  full  and  slow,  and  some- 
intermittent,  times  labouring. 
The  stomach  sickens  and  re-       The  stomach  is  insensible  to 
jects  its  contents.  any  impression;  no  nausea 

or  vomiting. 
The  fasces  may  be  discharged       Bowels   are   torpid,   and   the 
incontinently,  as  may  also  bladder  incapable  of  einpty- 

the     urine,     though     not  ing  itself,  though  the  urine 

usually.  may  escape  by  overflow. 

Deglutition  little  impaired.  Deglutition   difficult    or    im- 

possible. 
Pupils  variable,  though  gen-       Pupils  variable,  though  gen- 
erally contracted ;  the  eye-  erally  much    dilated,    and 
lids  somewhat  open.                        the  eyelids  closed. 
Temperature  of  the  body  less       Temperature   almost  natural, 
than  natural.                                    a  little  below   the   normal 

standard. 

"  No  surgeon,  however,  will  have  been  long  engaged 
in  hospital  practice  before  he  discovers  that  these  sharp 
diflferential  distinctions  are  subject  to  great  variations 
and  modifications.  Notwithstanding  these  irregu- 
larities, however,  there  remains  a  large  number  of 
cases  in  which  the  time-honoured  distinctions  hold 
good,  and  possess,  therefore^  a  practical  value." 

It  must  also  be  borne  in  mind  that  the  word  com- 
pression comprehends  every  variety  of  brain  pressure, 
from  that  produced  by  a  spicule  of  bone  to  that  of  a 
large  abscess  or  malignant  growth.  Some  of  its 
causes  may  be  complications  of  concussion,  for  ex- 
ample, contusion,  laceration,  and  ruptured  blood- 
vessels, which  have  been  enumerated  as  such.  But 
as  compression  is  the  more  chronic  state,  and  is  that 
in  which,  whilst  surgical  interference  may  be  necessary, 
more  time  is  available  for  consideration,  it  is  well  to 
dwell  on  the  various  conditions  which  may  co-exist,  or 
which  may  successively  present  themselves,  with  a 
view  to  diagnosis  and  treatment. 

Thus,  compression  is  an  extremely  complex  state, 


412 


Manual  of  Surgery. 


and  its  symptoms,  prognosis,  and  treatment  differ  so 
widely  in  cases  at  the  two  extremes,  that,  in  my 
opinion,  a  further  division  of  the  term  is  greatly  to  be 
desired.  Those  cases,  for  example,  which  arise  from 
a  spicule  of  bone,  a   small  foreign   body,   a  localised 

inflammation,  or  other 
limited  lesion,  I  propose 
to  designate  by  the  term 
"  local  cerebral  irrita- 
tion,'' leaving  the  more 
comprehensive  w  o  r  d 
"  co)npression "  to  in- 
clude those  cases  in 
which  extensive  pres- 
sure is  manifested  either 
by  cause  or  effect.  Such 
a  division  would  be  more 
in  consonance  with  mo- 
dem ideas  of  the  localisa- 
tion of  cerebral  func- 
tions. 

Tersniiiatioiis  of 
coiii|>i'e!^<i»ioii.  —  The 
symptoms  of  compres- 
sion may  disappear  after  a  certain  period,  sometimes 
spontaneously,  sometimes  following  on  treatment;  but 
in  other  cases  they  persist,  and  a  fatal  termination 
may  result,  without  any  indication  for  operative  in- 
terference. 

]>iflrei'eiitiatioii  of  tlic  vai'ii'tic«>)  of  coiii- 
preission. — As  has  been  seen,  the  causes  of  com- 
l)ression  vary,  and  it  is  important  to  differentiate 
these.  If  the  symptoms  of  compression  exist  from 
the  beginning,  however  those  symptoms  may  be 
obscured  ])y  the  signs  of  concussion,  it  may  be  sus- 
pected that  depressed  fracture,  foreign  body,  or  some 
serious  brain  lesion    exists,   and    if    the    history    of 


Ficr.  87.  -Compression  of  the  Brain 
due  to  extensive  Extra  vixsation  of 
Blood.     (After  Hiitcliiusou.) 


Compression. 


413 


tlie  case,  or  the  apparent  cause  of  the  condition,  such 
as  a  fall  on  the  head,  be  accompanied  by  the  signs  of 
compression,  we  are  safe  in  assuming  the  presence  of 
a  depressed  fracture  or  a  foreign  body ;  whilst  if  the 
signs  of  concussion  disappear,  and  those  of  compression 
gradually  supervene,  after  the  lapse  of  a  period  from 
one  to  forty-eight  hours  after  the  injury,  extra vasated 
blood  is  probably  the  cause.  Such  cases  as  the 
following  are  not  uncommon,  and  they  may  some- 
times involve  the  surgeon  in  unmerited  blame  : 

A  man  is  thrown  from  a  vehicle  on  his  head  and  is  brought 
to  the  nearest  surgery  or  hospital  in  a  state  of  concussion.  He 
recovers  more  or  less  quickly,  and  insists  on  proceeding  home- 
wards, contrary  to  the  urgent  ad\ice  of  the  surgeon.  Perhaps 
he  hastens  reaction  by  taking  stimulants,  and  in  some 
hours  afterwards  he  becomes  drowsy,  stupid,  and  falls  fi-om 
his  seat.  Complete  insensibility  and  all  the  other  signs  of 
compression  supervene,  and  death  closes  the  scene.  What  is 
the  explanation  ?  The  middle  meningeal  or  other  vessel  had 
been  ruptured  at  the  time  of  the  accident,  and  during  the 
collapse  state  of  concussion,  when  the  heart's  action  was  more 
or  less  in  abeyance,  a  clot  formed  at  the  seat  of  injury,  which 
stemmed  the  tide  of  extravasation.  But  with  the  establish- 
ment of  reaction  (perhaps  too.  vigorous)  the  clot  had  been 
swept  away,  and  the  cerebral  ha-morrhage  proceeded  un- 
checked, either  between  the  bone  and  dura  mater,  or  upon  the 
surface,  or  within  the  substance  of  the  brain  itself,  and  that 
haemorrhage  produced  the  fatal  coma. 

Compression  by  serum  or  lymph  may  be  suspected 
if  the  symptoms  arise  in  the  early  stages  of  encephalitis 
or  meningitis,  and  in  these  cases  it  is  fortunate  that 
diagnosis  is  not  so  important,  as  there  can  be  no 
surgical  interference,  and  a  reliance  on  the  general 
remedies  can  alone  be  inculcated. 

At  a  later  period,  when  inflammation,  in  whatever 
structure  it  may  originate,  has  produced  suppuration, 
a  condition  which  is  indicated  by  rigors,  by  the 
presence  of  Pott's  puffy  tumour  (an  appearance  so 
rare  that  many  experienced  surgeons  have  never  seen 


414  Manual  of  Surgery. 

it),  or  by  the  state  of  the  bo2ie  if  it  be  bare,  the 
existence  of  the  effused  pus  may  be  diagnosed,  and  its 
probable  position  should  be  considered.  It  may 
have  been  formed  between  the  skull-cap  and  the 
dura  mater,  as  when  the  puffy  tumour  is  present,  or 
where  the  bone  is  manifestly  dead  ;  or  it  may  be 
diffused  upon  the  surface  of  the  brain,  or  circumscribed 
betw-een  adherent  membranes,  or  in  the  subarachnoid 
spaces,  or  in  the  brain  substance  itself. 

Our  knowledge  of  the  modern  topographical 
anatomy  of  the  brain  may  lead  us  in  doubtful  cases 
to  suspect  a  pressure  limited  to  a  particular  spot.  In 
such  cases  operations  may  be  attempted  with  hope,  as 
they  have  been  performed  with  success. 

It  must  be  remembered  that  compression  may 
exist  to  a  considerable  extent,  especially  when  slowly 
induced  by  the  gradual  formation  of  matter,  or  the 
slow  growth  of  a  tumour,  and  that,  nevertheless,  few 
of  the  symptoms  described  as  belonging  to  compression 
will  be  manifested,  or  they  only  mark  the  termination 
of  the  case.  On  the  other  hand,  it  may  occur  that 
though  all  the  symptoms  are  present,  a  post-mortem 
examination  gives  very  negative  proof  of  the  existence 
of  any  appreciable  compressing  cause. 

It  is  in  cases  where  coma  is  not  so  marked  or  per- 
sistent, where  limited  primary  spasms  or  paralyses  are 
present,  where  aphasia,  or  the  implication  of  certain 
groups  of  muscles  point  to  an  irritation,  such  as  that 
which  a  localised  compression  may  produce,  that 
operative  interference  is  most  hopeful,  and,  although 
these  symptoms  may  be  almost  altogether  absent,  yet 
the  existence  of  an  obvdous  cause,  such  as  in.  punc- 
tured fracture,  or  foreign  body,  will  at  once  suggest 
operation,  and  encourage  hope  of  success. 

With  regard  to  peripheral  in<llcatioiis  of 
centric  lesions,  it  is  desirable  to  direct  atten- 
tion to  the  great  difficulty  of  recognising  these  in  many 


Death  in  Head  Injuries.  415 

cases ;  but  tins  difficulty  may  often  be  met  by  a  due 
consideration  of  the  locality  of  the  injury,  and  its 
anatomical  relations.  Thus,  for  example,  fissure  of  the 
petrous  bone  is  almost  with  certainty  indicated  by 
what  have  been  called  the  triad  of  symptoms,  namely, 
bleeding  from  the  ear,  deafness,  and  Bell's  paralysis. 
If  unconsciousness  from  any  cause  be  present,  only 
one  of  these  can  be  recog-nised  with  certainty. 

Again,  if  the  patient  be  conscious,  the  diagnosis  of 
hemiplegia  is  attended  with  no  difficulty,  and  spasm 
or  paralysis  of  any  groups  of  muscles  functionally 
associated,  can  be  easily  ascertained ;  but  if  he  be 
comatose,  it  requires  both  experience  and  care  to 
recognise  their  presence.  Slight  facial  palsy  is,  under 
any  circumstances,  difficult  to  detect ;  but  if  it  be 
pronounced,  the  whiffing  respii'ation,  the  passive  alse 
nasi,  the  twisted  mouth,  or  the  permanently  open  eye, 
may  prove  its  existence  even  in  insensibility.  This 
condition  is  still  further  obscured  if  symmetrical  or  if 
a  bi-lateral  lesion,  differing  in  intensity  in  the  two 
hemispheres,  affect  the  opposite  nerves  to  a  different 
extent.  The  presence  of  hemiplegia  affecting  the 
limbs  in  such  a  case  is  also  difficult  to  ascertain.  If 
the  paralysed  arm  or  leg  be  raised  and  allowed  to  drop, 
it  falls  with  a  deadness  that  may,  as  compared  with 
that  of  the  opposite  side,  be  recognised  by  the  ex- 
perienced surgeon.  But,  on  the  other  hand,  this  may 
not  be  so,  and  it  may  require  close  and  continuous 
obserA^ation  to  satisfy  the  surgeon  that  movements 
take  place  occasionally  on  one  side,  and  that  the  limbs 
of  the  opposite  side  remain  persistently  motionless. 

Pathological  conditions  foiieicl  after  death 
from  head  injuries. — The  most  usual  are  (1)  bone 
disease  with  necrosis  or  osteo-phlebitis  and  remote 
evidences  of  pyaemia,  or  with  secondary  intracranial 
mischief ;  (2)  arachnitis,  localised  or  extensive,  with 
serum,  lymph,  or  pus  in  the  cavity  of  the  arachnoid ; 


4t6  Manual  of  Surgery. 

(3)  inflammation  with  lymph  or  piiriform  fluid  in  the 
subarachnoid  spaces  ;  (4)  inflammation  of  the  brain 
substance  itself,  with  or  without  suppuration. 

Although  it  is  not  always  possible  during  life  to 
diflferentiate  these  conditions,  there  are  certain  symp- 
toms which  appear  more  prominent  when  one  or  other 
of  them  predominates.  Thus,  if  the  bone  injury  lead  to 
pyaemia,  in  addition  to  the  local  signs,  the  occurrence 
of  repeated  rigors  is  much  insisted  on  by  Hutchinson 
as  a  pathognomic  sign.  When  secondary  hemiplegia 
occurs,  accompanied  by  rise  of  temperature,  quick 
pulse,  headache,  delirium,  intolerance  of  light  and 
sound,  restlessness  and  sleeplessness,  and  other  signs 
of  meningitis,  the  same  authority  believes  that  the 
arachnoid  is  especially  the  seat  of  the  disease.  In- 
flammation of  the  subarachnoid  spaces,  with  purulent 
exudation,  he  considers  follows  injuries  of  the  base, 
especially  where  nerve  trunks  are  involved  close  to 
their  cerebral  origin,  and  this  condition  is  indicated 
by  gradual  advance  of  symptoms,  hemiplegia  being 
absent.  Dilatation  and  fixation  of  the  pupil  or 
pupils,  accompanied  by  external  strabismus,  indicate 
implication  of  the  third  pair  of  nerves,  while  if  the 
tongue  be  thickly  coated,  the  fifth  pair  is  involved ; 
and  if  there  be  a  tendency  to  pneumonia,  most 
probably  functional  lesion  of  the  pneumogastric 
has  occurred.  Inflammation  of  the  brain  substance 
occurs  primarily  as  the  result  of  injuries  to  its 
substance,  and  secondarily  by  extension  from  its 
membranes. 

Eiiccplialitis  and  iiiciiiiig:itis. — When  intra- 
cranial inflammation  supervenes,  as  either  the  result  of 
concussion,  or  from  direct  injury  of  the  brain  or  mem- 
branes, as  in  contusion,  laceration,  or  fractured  base, 
it  is  not  always  possible  to  say  how  far  the  symptoms 
are  those  of  meningitis  or  encephalitis,  and  at  an  early 
period  the  importance  of  a  difi'erential  diagnosis  is  not 


Cerebral  Abscess.  417 

very  great,  the  treatment  being  the  same  for  both  con- 
ditions. Later,  when  cerebral  abscess,  or  localised 
meningeal  suppuration  may  be  present,  the  indica- 
tions for  interference  will  be  much  the  same  in  both 
cases,  and  even  when  abscess  accompanies  or  follows 
diseased  bone  where  it  might  be  reasonably  expected  to 
occupy  a  superficial  position,  such  as  between  the 
bone  and  dura  mater,  it  is  not  unfrequently  found  in 
the  brain  substance  itself. 

The  general  treatment  for  encephalitis  and  menin- 
gitis has  already  been  described  under  the  head  of 
traumatic  intracranial  inflammation.  Post-mortem 
appearances  in  such  a  case  vary  very  much.  If  the 
dura  mat^r  be  alone  afiected,  consequent  on  traumatic 
osteitis  or  its  sequelae,  thickening  and  increased  vas- 
cularity, or  even  localised  sloughing  of  the  membrane 
may  be  found,  as  in  periostitis  elsewhere.  If  the 
arachnoid  be  involved,  the  inflammation  is  usually  dif- 
fuse, and  may  extend  over  both  hemispheres,  and  the 
cavity  of  the  membrane  may  contain  lymph  or 
puriform  exudations  of  a  yellowish-green  colour. 
This  condition  may  be  complicated  by  the  existence 
of  fibrinous  masses  or  pseudo-cysts,  the  result  of 
preceding  extravasation  of  blooct  When  the  pia 
mater  is  aflfected,  there  may  be  extensive  puriform 
efTusion  with  great  congestion  of  the  vessels.  Some- 
times the  matter  in  the  subarachnoid  spaces  seems 
to  gravitate  downwards  along  the  larger  vessels  to- 
wards the  base  of  the  brain,  or  the  medulla  oblongata. 
Encephalitis  may  follow  meningitis,  or  it  may  be 
primary,  and  may  affect  the  cortical  or  medullary 
structures,  or  both.  The  grey  substance  may  be 
softened,  and  be  of  a  dark  leaden  hue.  The  white 
substance  resists  the  softening;  and  disintecrratins: 
process  to  a  gi-eater  extent  than  the  grey  matter,  except 
as  the  result  of  a  direct  injury. 

Cerebral  abscess  may  be  de?;cribed  as  of  two 
B  B— 21 


41 8  Manual  of  Surgery, 

kinds,  acute  and  chronic  ;  the  first  variety  follcW' 
ing  immediately  on  encephalitis,  and  the  second 
manifesting  itself  at  a  considerable  period  after  the 
receipt  of  the  injury,  and  with  few  symptoms  of 
antecedent  inflammation. 

If,  in  the  course  of  a  case  of  encephalitis,  a  well- 
marked  rigor  occurs,  and  symptoms  of  irritation  of,  or 
pressure  upon,  one  or  more  of  the  motor  areas  exhibit 
themselves,  or  at  a  more  remote  period  similar 
symptoms  are  recognised,  the  presence  of  cerebral 
abscess  may  be  suspected.  The  existence  of  optic 
neuritis,  too,  may  lend  an  additional  aid  to  the 
diagnosis. 

Injuries  to  the  Cranial  Nerves. 

First  pa-ir. — The  olfactory  nerves  can  scarcely  be 
materially  injured,  excejjt  in  fractures  of  the  base,  and 
here  the  nerve  injury  is  of  little  importance.  Loss 
of  smell  has  occasionally  followed  injuries  of  the 
vault,  possibly  from  contusion  of  the  nerve  or  adjacent 
portion  of  the  brain. 

The  second  pair  may  be  torn  across,  or  contused, 
or  pressed  on  by  broken  bone  or  extra vasated  blood, 
and  loss  of  sight,  more  or  less  complete,  is  the 
immediate  result.  This  may  be  permanent,  or  recovery 
may  follow  when  the  nerve  lesion  is  produced  by 
contusion  or  extra  vasated  blood. 

TItird  pair. — These  nerves  are  very  frequently 
affected  in  injuries  of  the  head,  and  the  symptoms 
vary  with  the  amount  of  injury  ;  thus,  irritation  may 
produce  spasm,  as  indicated  by  contracted  pupil, 
internal  strabismus,  and  partial  lagophthalmos,  while 
complete  paralysis  of  the  nerve  is  shown  by  the  oppo- 
site set  of  symptoms. 

Foiirtli  pair. — No  special  lesion  of  this  pair  has 
been  noticed,  or,  at  least,  no  symptoms  described  io 
reference  to  it. 


Hernia  Cerebri.  419 

Fittti  pail*. — It  has  been  mentioned  that  a  thick 
white  coating  of  the  tongue,  quickly  following  on 
cranial  injury,  probably  depends  on  some  structural  or 
functional  disturbance  afiecting  this  nerve.  If  this  be 
associated  with  w^ant  of  sensation,  including  not  only 
the  tongue,  but  the  side  of  the  face  and  conjunctiva, 
the  diagnosis  of  injury  of  the  trifacial  is  more  certain. 
At  a  more  remote  period  opacity  or  ulceration  of  the 
cornea  has  been  known  to  occur.  The  paralysis  of  the 
fifth  may  be  temporary  or  permanent,  according  to  the 
cause. 

Sixth  pair.— Paralysis  of  this  nerve  is  likely  to 
occur  in  fracture  of  the  base ;  internal  strabismus  will 
indicate  the  injury. 

Seventh  pair. — The  portio  dura  and  auditory 
may  be  injured  together,  as  manifested  by  deafness  and 
facial  palsy,  or  either  separately  may  be  involved, 
as  shown  by  the  single  group  of  symptoms  belonging 
thereto. 

Eighth  pair. — From  their  position  they  are  not 
likely  to  be  affected,  except  in  fractures  of  or  extrava- 
sations about  the  base.  Difficulty  in  swallowing  will 
point  to  the  involving  of  these  nerves,  whilst,  as  has 
been  mentioned,  unusual  tendency  to  pneumonic  com- 
plication will  strengthen  the  diagnosis. 

The  ninth  pair  of  nerves  will  be  probably  impli^ 
Gated  in  the  same  class  of  lesion,  and  be  indicated  by 
paralysis  of  the  tongue. 

Hernia  Cerebri. 

When  a  portion  of  the  cranial  vault  is  removed  by 
injury  or  by  operation,  and  an  ajDerture  thereby  made 
in  the  dura  mater,  a  fungous  mass  may  gradually  pro- 
trude, to  which  the  name  hernia  or  fungus  cerebri  has 
been  assigned. 

True  hernia  cerebri,  an  outgrowth  from  the  brain 
itself,  forms  a  more  or  less  mushroom-shaped  tumour, 


420  Manual  of  Surgery, 

attached  by  a  pedicle  situated  at  the  opening  in  the  skull, 
and  presenting  an  expanded  portion  which  projects 
above  and  around  the  orifice.  True  brain  substance 
has  been  found  in  this,  also  blood  and  granulation  tis- 
sue ;  but,  nevertheless,  it  has  not  been  fully  explained 
how  such  a  protrusion  occurs,  and  how  it  develops 
so  rapidly.  Probably  it  may  arise  from  hyjDeraemia  ex- 
tending in  the  direction  of  least  resistance,  leading  to  a 
projection  of  brain  substance  and  inflammatory  pro- 
ducts, associated  with  irregular  vascularity  and  fluid 
accumulations  in  the  substance  of  the  contiguous 
brain.  This  form  of  protrusion  may  be  vascular  and 
pulsatile,  firm  or  soft,  and  sloughing  of  the  surface 
may  occur  synchronously  with  the  growth.  It  is  a 
very  fatal  complication,  about  seventy  per  cent,  of 
the  cases  dying  (Nancrede). 

As  hernia  cerebri  seems  to  arise  from  irritation, 
and  from  want  of  the  natural  pressure  of  the  bone, 
the  rational  treatment  is  the  removal  of  all  the  causes 
of  that  irritation,  and  the  use  of  compresses  of  lint  or 
cotton,  antiseptically  prepared,  and  strict  attention 
to  cleanliness. 

Terminatioiis  of  injuries  of  the  head. — 
(1)  Recovery,  which  may  be  partial  or  complete  ;  (2) 
death,  immediate  or  subsequently,  from  the  remote 
efiects. 

There  is  scarcely  any  injury  of  the  skull,  as  has 
been  already  remarked,  from  which  complete  recovery 
may  not  take  place  ;  but  in  a  number  of  cases,  larger, 
perhaps,  than  may  be  reported,  recovery,  with  some 
appreciable  morbid  conditions,  occurs. 

Thus,  immediately  or  at  a  remote  period,  the 
patient  may  sufler  from  insanity,  epilepsy,  diabetes, 
hemiplegia,  or  other  partial  paralysis,  or  from  im- 
pairment of  some  of  the  special  senses.  Even  with- 
out such  perceptible  lesions,  a  certain  delicacy  or  irrit- 
ability of  brain  may  result,  which  will  display  itself 


Tr  ep  mining.  421 

by  alterations  of  temper,  especially  when  alcoholic 
drinks  have  been  taken,  or  when  the  intellect  has 
been  over  -  exercised,  or  the  emotions  abnormally 
excited.  Many  of  the  complications  may  be  the 
remote  causes  of  death.  When  a  fatal  termination 
occurs  immediately  it  is  probably  due  to  severe  con- 
cussion, contusion,  or  laceration  of  brain,  or  to  com- 
pression from  extravasation  of  blood.  But  if  death 
occur  later  on,  inflammation,  with  its  products,  will  be 
responsible.  If  recovery  from  the  accident  and  from 
its  immediate  consequences  occur,  epilepsy  or  diabetes 
may  destroy  life  after  the  lapse  of  some  months  or 
years,  injuries  of  the  occipital  region  being  most 
frequently  the  causes  of  the  latter. 

Trephining. 

The  operation  of  trephiiiin  which  is 
meant  to  include  all  kinds  of  interference  with  the 
bone,  whether  with  the  trephine,  Hey's  saw,  the 
forceps,  or  the  elevator,  may  be  required  in  the  follow- 
ing cases  :  {a)  Compound  depressed  fracture,  when 
the  amount  of  depression  exceeds  the  thickness  of  the 
bone ;  in  other  words,  where  a  probe  can  be  slipped 
in  on  tlie  surface  of  the  displaced  fragment  be- 
neath the  undepressed  surrounding  margin  (Hewitt). 
There  is  one  exception  to  this  rule.  In  children 
the  bone  is  rarely  extensively  splintered,  the  dura 
mater  is  more  pliant,  and  the  brain  is  more 
tolerant  of  pressure,  and,  therefore,  in  these  cases 
trephining  may  be  delayed  till  symptoms  appear. 
(6)  In  punctured  fracture  j  (c)  in  simple  depressed 
fracture,  with  grave  symptoms  persistent ;  (c?)  when 
\  a  foreign  body  is  present ;  (e)  wlien  dead  bone  exists 
as  the  result  of  injury,  with  denudation  of  mem- 
branes or  osteo-myelitis ;  (/)  when  blood  clot  occurs 
between  the  bone  and  dura  mater,  if  diagnosed  and 
accessible ;  {g)  when  intracranial,  <iircumscribed,   and 


42  2  Manual  of  Surgery. 

localised  suppuration  is  detected,  with  symptoms  of 
compression  or  irritation ;  [h)  remotely,  in  point  of 
time,  if  persistent  epilepsy,  or  insanity,  or  localised 
incurable  headache  follow,  as  the  result  of  depressed 
or  punctured  injury,  or  if  the  symptoms  point  to  a 
limited  and  removable  source  of  irritation ;  (i)  pond 
and  gutter  fractures,  if  compound,  hold  the  same 
position  as  compound  depressed  fracture,  and,  if  they 
be  simple,  operation  may  still  be  necessary. 

The  coutra-indications  to  operation  are, 
first,  very  profound  coma  or  other  symptoms,  which 
may  indicate  that  the  cause  of  the  condition  is  ex- 
treme extravasation  of  blood  into  or  on  the  surface  of 
the  brain,  or  fracture  of  the  base  of  the  skull. 
Secondly,  the  situation  of  the  injury,  as  that  of  the 
orbits,  or  of  the  roof  of  the  nose,  though  in  these 
cases  the  removal  of  a  foreign  body  or  of  loose  frag- 
ments of  bone  would  not  be  contra-indicated.  Thirdly^ 
trephining  over  the  sutures  is  inadvisable,  in  con- 
sequence of  the  firm  attachment  of  the  dura  mater  in 
these  situations  to  the  bone  ;  but  this  may  be  dis- 
regarded if  the  indications  for  the  operation  be  im- 
perative. Fourthly,  trephining  over  the  venous 
sinuses  or  course  of  the  meningeal  arteries  is  to  be 
avoided,  if  possible.  Fifthly,  the  presence  of  motor 
indications,  as  spasm  or  paralysis  on  hoth  sides  of  the 
body,  pointing  to  lesions  of  the  two  hemispheres,  also 
contra-indicates  operation.  And,  sixthly,  trepliining  in 
a  case  of  any  injury  of  the  cranium  with  insensibility  is 
not  to  be  contemplated  until  the  other  great  cavities 
have  been  thoroughly  examined,  and  the  presence  of 
lethal  lesions  in  them  negatived. 

From  many  observations  I  have  made,  and  from 
the  study  of  collected  cases  in  which  epilepsy,  insanity, 
dementia,  and  other  mental  troubles  have  followed 
upon  unrelieved  depressed  fractures,  I  believe  that,  if 
cases  of  dej^ressed  fracture  of  the  skull  left  to  nature 


Trephining.  423 

could  be  subsequently  traced,  they  would  afford  a 
powerful  argument  for  primary  trephining ;  and  it 
must  be  borne  in  mind  also  that  this  operation  in 
compound  depressed  fracture  can  scarcely  add  to  the 
risks  of  osteo-phlebitis,  which  the  procedure  has  been 
credited  with  producing.  A  more  important  plea  for 
the  safety  of  the  operation  is  afforded  by  the  results 
in  surgery  of  modern  antisepticism  carried  out  with 
rigorous  precautions.  The  dangers  of  septicaemia 
from  operative  interference  are  minimised,  and  in  any 
case,  where  it  seems  necessary,  the  operation  may  be 
thus  performed  without  running  the  risk  of  being 
held  accountable  for  any  subsequent  want  of  success. 

CereBn'al  topog^rapliy  in  relation  to  ssnr- 
g'ical  iaijMi'ies. — Without  dwelling  on  the  vexed 
question  of  localised  cerebral  functions,  there  is  no 
doubt  that  there  exists  a  connection  between  certain 
areas  of  the  brain,  motor  centres,  and  certain  periplieral 
regions,  sufficient  to  afford  in  many  cases  an  indication 
of  localised  brain  lesion.  To  give  practical  effect  to 
the  conclusions  which  these  views  point  to  it  is  neces- 
sary first  to  be  acquainted  with  these  centres. 

Motor  centres  of  t!ie  cortex.— The  followin<y 
description  from  Treves'  "  Surgical  Applied  Anatomy  " 
briefly  indicates  these  centres,  according  to  the  views  of 
the  three  highest  authorities. 

"  According  to  Charcot,  (1)  centre  for  movements 
of  the  tongue  at  the  posterior  end  of  the  third  frontal 
convolution  and  contiguous  part  of  the  ascending 
frontal  convolution ;  (2)  movements  of  lower  part  of 
face  at  the  lower  end  of  the  two  ascendinof  con- 
volutions ;  (3)  centre  for  fore-arm  and  hand  on  the 
middle  third  of  the  ascending  frontal  convolution ; 
(4)  centre  for  movements  of  the  lower  limb  on  the 
upper  third  of  the  ascending  frontal  convolution 
and  upper  two-thirds  of  the  ascending  parietal  con- 
volution.    According  to  Ilitzig,  (1)  motor  centre  for 


424 


Manual  of  Surgery. 


upper  limb  at  upper  part  of  ascending  frontal  con- 
volution ;  (2)  motor  centre  for  lower  limb  on  ascending 
frontal  convolution,  just  below  preceding  centre ;  (3) 
motor  centre  for  facial  muscles  at  middle  part  of 
ascending  frontal  convolution  ;  (4)  centre  for  muscles 
of  mouth,  tongue,  and  jaws  at  inferior  part  of  ascending 
frontal  convolution.     According  to  Ferrier,  (1)  centre 


Fig.  88.— Diagram  to  show  the  Relation  of  the  chief  Cranial  Sutures 
to  the  Surface, 


for  rotation  movements  of  liead  and  neck  at  posterior 
end  of  first  frontal  convolution  ;  (2)  centre  for  muscles 
of  face  at  posterior  end  of  second  frontal  convolution ; 
(3)  centre  for  articulate  language  on  posterior  part  of 
third  frontal  convolution ;  (4)  centre  for  upper 
limb  at  upper  end  of  ascending  frontal  convolution ; 
(5)  centre  for  lower  limb  on  upper  two-thirds  of 
ascending  parietal  convolution  and  jiart  of  superior 
parietal  lobule." 

To  make  this  cerebral  localisation  useful  to  the 


TRErniNING. 


425 


surgeon  it  is  necessaiy  to  give  the  guiding  points  of 
the  head,  which  indicate  the  exact  positions  of  the 
fissures,  convolutions,  and  motor  centres  alluded  to  in 
the  preceding  quotation. 

Relations  of  the  hrain  to  the  skull  (Treves). — 
"Tlie  lower  level  of  the  brain  in  front  corresponds 
to  a  line  drawn  across   the  forehead  just   above   the 


Fig.  89. — Diagram  to  show  the  Eelation  of  the  Main  Fissures  to  the 
Surface  of  the  Skull.     (From  Treves'  "  Surgical  Applied  Anatomy.'') 

eyebrows.  At  the  side  of  the  head  it  corresponds 
approximately  to  a  line  drawn  from  a  point  half  an 
inch  above  the  external  angular  process  of  the  frontal 
to  the  upper  part  of  the  external  auditory  meatus. 
A  line  drawn  from  this  latter  spot  to  the  occipital 
protuberance  corresponds  to  the  lo'wer  level  of  the 
posterior  lobe,  while  below  that  line  will  lie  the 
cerebellum.  The  commencement  of  the  Sylvian 
fissure  corresponds  to  the  pterion.  Its  ascending 
limb   is   parallel   to,   and    immediately    behind,   the 


426  Manual  of  Surgery. 

coronal  suture.  Its  posterior  or  horizontal  limb  runs 
backwards  across  the  upper  margin  of  the  squamous 
suture.  The  external  parieto-occipital  fissure  is  a 
little  in  front  of  the  lambda.  The  fissure  of  Rolando 
is  some  way  behind  the  coronal  suture,  and  is  not 
quite  parallel  to  it,  being  a  little  less  than  two  inches 
behind  the  suture  above,  and  a  little  more  than  one 
inch  behind  it  below. 

The  temporo-sphenoidal  lobe  lies  below  a  line 
drawn  horizontally  backwards  from  the  external 
angular  process.  To  find  Broca's  convolution  (the 
posterior  part  of  the  third  left  frontal  convolution), 
a  horizontal  line  is  drawn  backwards  from  the 
external  angular  process  for  two  inches.  The  con- 
volution is  three-quarters  of  an  inch  above  the  end  of 
this  line.  The  upper  borders  of  the  optic  thalamus 
and  corpus  striatum  are  about  on  a  level  with  the 
top  of  the  pinna.  They  are  situate  opposite  the 
temporal  region,  and  the  anterior  limit  of  the  corpus 
striatum  about  corresponds  to  tlie  pterion."  (^S'ee 
Fig.  89.) 


427 


IX.     DISEASES  OF  THE  SPINE. 

Herbert  W.  Page. 

Spina  Bifida  * 

is  the  name  given  given  to  "  certain  congenital  mal- 
formations of  the  vertebral  canal,  with  protrusion 
of  some  of  its  contents  in  the  form  of  a  fluid 
tumour.  With  very  rare  exceptions,  the  malforma- 
tion aifects  the  neural  arches  of  the  vertebrae,  and 
the  tumour  projects  posteriorly ;  in  rare  cases,  how- 
ever, the  malformation  involves  the  bodies  of  the 
vertebrae,  the  tumour  in  such  cases  protruding  an- 
teriorly  into  the  thorax,  abdomen,  or  pelvis  between 
the  lateral  halves  of  the  bodies  affected."  The  bifid 
condition  of  the  neural  arch  is  essentially  due  to 
defective  development  of  that  part  of  the  mesoblast 
from  which  the  structures  closing  in  the  vertebral 
furrow  are  derived.  The  result  is  a  gap,  fissure,  or 
cleft  in  the  vertebral  arches,  whereby  the  spinal 
canal  at  the  affected  points  remains  open. 

The  commonest  site  of  the  defect  is  in  the  lumbo- 
sacral region,  but  it  may  rarely  be  found  in  the 
upper  cervical,  and  much  less  often  in  other  parts  of 
the  column.  The  cleft  may  vary  enormously  in  size, 
and  involve  the  arch  of  one  vertebra  or  of  many. 
The  fluid  tumour  usually  occupies  the  middle  line, 
and  presents  every  variety,  both  in  size  and  appear- 
ance. 

There  are  three  main  varieties  of  spina  bifida  :  (1) 
those    in    which    membranes    alone    protrude,   spinal 

*  Quotations  in  tliis  part  of  tlie  article  are  from  the  recent 
"Report  of  the  Committee  on  Spina  Bifida,"  Clin.  Soc.  Trans,, 
vol.  xviii.,  to  which  the  reader  must  refer  for  the  best  informa- 
tion on  the  subject. 


428  Manual  of  Surgery. 

meningocele;  (2)  those  in  wliich  "membranes,  to- 
gether with  the  spinal  cord  and  its  appertaining 
nerves,  protrude,  meningo-myelocele ;  "  and  (3)  those 
■where  there  is  "  protrusion  of  the  membranes,  together 
with  the  sj)inal  cord,  the  central  canal  of  which  is 
dilated  so  as  to  form  the  sac  cavity,  the  inner  lining 
being  constituted  by  the  expanded  and  atrophied  sub- 
stance of  the  cord,  syringo-myelocele.^^  The  second  is 
by  far  the  commonest,  the  last  is  the  rarest. 

Symptoms. — Associated  very  often  with  the 
spina  bifida,  and  indicative  of  the  implication  of  nerve 
elements  in  the  tumour,  are  paralyses,  more  or  less, 
of  the  lower  limbs  or  sphincters,  some  degi'ee  of  club 
foot,  talipes  equino-varus  being  the  most  frequent, 
with  perhaps  a  generally  stunted  appearance  of  the 
whole  limb,  which  may  be  cold  and  blueish.  There 
is  often  also  hydrocephalus,  and  pressure  on  the 
sacral  tumour  may  increase  the  distension  of  the 
head  and  cause  convulsions  or  other  grave  disturb- 
ances. 

The  form  and  size  of  the  sac  vary  enormously.  It 
is  usually  about  the  size  of  a  Tangerine  orange  at  birth 
(Fig.  90).  "  In  form  sessile,  somewhat  constricted  at 
the  base,  cii'cular,  ovoid,  or  cordiform  in  outline,  these 
tumours  occasionally  present  a  slight  median  longi- 
tudinal furrow,  or  sometimes  a  more  localised  depres- 
sion at  or  near  the  summit,  the  so-called  umbilicus. 
The  latter  indicates  the  spot  at  which  the  spinal  cord 
meets  and  becomes  incorporated  with  the  posterior 
wall  of  the  sac;  but  whilst  its  presence  indicates 
that  the  tumour  is  a  meningo-myelocele,  its  absence 
cannot  be  held  to  show  the  contrary.  The  same  is 
true  of  a  median  furrow." 

The  coverings  of  the  sac  also  show  great  varieties. 
"  It  is  very  seldom  that  a  normal  cutaneous  covering 
exists  over  the  whole  protrusion.  As  a  rule,  the  base 
alone  is  covered  with  normal  skin,  while  in  the  rest 


Spina  Bifida. 


429 


of  its  extent  the  covering  consists  of  a  thin,  white, 
glistening  membrane-like  tissue.  In  some  specimens 
the  skin  ends  abruptlr,  in  others  it  merges  gi'adiially 
into  tlie  membrane  noticed.  More  rarely,  however, 
the  cutaneous  covering  is  continuous  over  the  whole 
tumour."  The  cleft  most  often  involves  several  verte- 
brae, "  most  usually  the  last 
lumbar  and  all  the  sacral." 
"  The  actual  extent  of  the 
protrusion  forms  no  certain 
criterion  of  the  extent  of 
deficiency  in  the  neural 
arches." 

In  the  second  and 
commonest  variety  it  has 
been  mentioned  that  a  de- 
pression or  furrow  indicates 
the  spot  where  the  cord 
meets  and  becomes  incor- 
porated with  the  posterior 
wall  of  the  sac.  "  The  level 
at  which  the  cord  crosses 
the  sac  is  variable ;  as  a 
rule,  it  is  somewhat  above 
its  centre.  Occasionally, 
however,  the  cord,  as  it 
emerges  from  the  vertebral 

canal,  becomes  immediately  connected  with  the  roof 
of  the  sac  without  the  intervention  of  any  space." 
The  integrity  of  the  central  canal  of  the  cord  is  pre- 
served at  this  part,  where  there  is  an  absence  of  true 
skin.  "  The  nerve  roots  which  traverse  the  sac  arise 
from  this  intramural  portion  of  the  central  nervous 
system.  .  .  .  The  sac  wall  is  really  their  source,  and 
the  nerves  within  the  sac  are  the  proper  anterior  and 
posterior  roots."  It  is  therefore  clear  that  the 
neural  furrow  does   not   remain   unclosed    in    spina 


Fig.  90.  -  Spina  Bifida. 


430  Manual  of  Surgery. 

bifida.  It  ic  the  vertebral  furrow  which  is  at 
fault. 

Prognosis. —  The  general  tendency  of  spina 
bifida  is  to  increase  in  size,  and  for  the  coverings  to 
become  thinner  and  thinner  until  they  burst ;  cerebro- 
spinal fluid  is  poured  out,  and  the  child  dies  from 
convulsions  or  meningitis.  In  the  smaller  tumours, 
however,  where  probably  the  cleft  is  small,  the 
coverings  are  of  skin  all  over,  and  there  is  simply 
a  meningocele,  spontaneous  recovery  is  by  no  means 
rare  ;  that  is  to  say,  the  fluid  gets  less,  the  walls 
shrivel  and  contract,  and  it  may  be  that  the  cleft  is 
closed. 

The  treatment  of  spina  bifida  has  always  been 
unsatisfactory,  and  interference  has  often  caused 
death.  Success  has  most  frequently  attended  the 
treatment  of  the  smaller  tumours,  which  have  a 
tendency  to  spontaneous  cure,  and  it  is  a  question 
whether  in  all  such  cases  the  surgeon  will  not  do 
wisely  to  be  content  with  protecting  the  tumour  from 
injury,  and  continuously  apply  gentle  pressure  so  as 
to  prevent  increase  in  size.  It  is  different,  however, 
with  rapidly  increasing  tumours,  which  are  associated 
with  grave  nervous  symptoms.  Various  methods  of 
treatment  have  been  adopted,  such  as  repeated 
tapping,  excision  and  ligature,  and  injection  with 
simple  iodine,  but  none  of  these  can  be  recommended. 
We  have,  in  injection  of  Morton's  iodo-glycerine 
solution  (iodine  gr.  x,  iodide  of  potassium  gr.  xxx, 
glycerine  5J)  ^  method  of  setting  up  a  process  of  cure 
which  consists  in  gradual  shrinking  of  the  tumour, 
and  which  closely  imitates  that  which  occurs  spon- 
taneously. "  The  puncture  into  the  tumour  should 
be  made  at  one  side  of  the  base,  obliquely  through 
healthy  skin,  and  not  through  membranous  sac'  wall. 
It  is  not  necessary  to  withdraw  any  of  the  fluid  con- 
tents of   the  tumour  before  injecting  the  solution." 


Coccygeal  Tumours.  431 

A  drachm  is  a  suitable  quantity  in  the  majority  of 
cases,  and  the  injection  may  be  repeated  in  about 
a  fortnight. 

"The  circumstances  which  contra-indicate  the 
operation  are  advanced  marasmus,  great  and  increasing 
hydrocephalus  and  intercurrent  disease.  As  a  rule  it 
is  well  to  wait  until  the  child  is  at  least  two  months 
old  before  submitting  it  to  operation;  but  when  the 
sac  wall  is  threatening  to  burst  treatment  may  be 
carried  out  earlier." 

The  cure  of  the  spina  bifida  offers  no  prospect 
of  improvement  in  any  paralysis  or  talipes.  Occi- 
pital meningocele  hanging  low  down  may  be  mis- 
taken for  cervical  spina  bifida.  Spina  bifida  is  more 
common  in  females  than  in  males.  The  tumours  may 
rarely  be  multilocular. 

Congenital  sacro-coccygeal  tiuiiours. — 
The  neighbourhood  of  the  sacrum  and  coccyx  is  a 
favourite  site  for  certain  congenital  tumours.  Of 
these  may  be  named  some  portion  of  a  foetus,  usually 
a  third  lower  limb ;  tumours  containing  foetal  remains 
such  as  bone,  cartilage,  hair,  and  teeth,  deeply  seated, 
perhaps,  and  adherent  to  bone,  often  pendulous,  and 
presenting  great  variety  in  both  size  and  contents, 
sometimes  associated  with  and  liable  to  be  mistaken 
for  spina  bifida,  especially  when  situated  higher  up 
than  usual  and  in  the  middle  line  ;  congenital  cystic 
tumours,  single  or  many-chambered,  some  of  which 
may  at  one  time  have  been  connected  with  a  sacral 
spina  bifida,  and  when  of  large  size  and  growing 
inwardly,  surrounding  the  rectum  and  other  pelvic 
organs  ;  congenital  solid  tumours,  fibrous,  fibro-cellular, 
and  fatty,  which  may  start  from  the  front  of  the 
sacrum  or  coccyx,  attain  vast  dimensions,  spread 
widely  in  the  pelvis,  and  surround  or  displace  all  the 
organs  contained  therein.  It  is  highly  probable  that 
many  of  these  congenital  tumours  arise  in  connection 


432  Manual  of  Surgery. 

with  embryonic  structures,  remaining  in  parts  where 
the  three  blastodermic  layers  are  brought  into  close 
apposition  in  the  process  of  development,  as  it  is  in 
certain  canals  which  become  obsolete  in  mammalia, 
such  as  the  post-anal  gut,  which  occupies  the  site  of 
these  teratomata. 

IMany  of  the  smaller  tumours  can  be  easily  re- 
moved ;  but  no  attempt  should  be  made  to  operate  on 
those  Avhich  extend  deeply  into  the  pelvis  until  their 
connection  with  the  pelvic  viscera  has  been  as  far  as 
possible  determined. 

Pott's  Disease. 

Pott's  disease  of  the  spine,  often  spoken  of 
as    "  angular    curvature,"    a  strange   misnomer,    is    a 
disease    commonly    of    early    life,    which    consists   in 
inflammation     and     necrotic     de- 
struction or  caries  of  some,  usually 
the  anterior,  pai-ts  of  the  vertebral 
bodies     and    intervertebral    discs, 
whereby  the  natural  support  given 
by  these  structures  to  the  column 
is  lost,   and  the    spine  above   the 
seat    of    mischief    falls    forwards, 
and  a  projection  is  caused  in  the 
Fig.  91.— Pott's  middle  line  of  the  back.      In  ex- 

Disease,  treme  cases,  such  as  that  shown  in 

the  accompanying  sketch  (Fig.  91), 
where  the  bodies  of  many  vertebrse  are  destroyed,  the 
angular  projection  is  very  great,  and  the  stature  of 
the  patient  is  diminished.  In  company  with  this 
bone  disease  there  is,  as  elsewhere,  the  formation  of 
an  abscess  which  may  present  itself  externally  in 
various  parts. 

Pathology, — The  morbid  process  is  closely  allied 
to,  if  it  be  not  identical  with,  that  of  caries  of  other 
bones.      The  lower  dorsal  region  is  the  commonest 


Pottos  Djsease.  433 

site  of  the  disease,  which  usually  begins  in  the 
anterior  part  of  one  or  more  bodies,  or  in  the  epi- 
physial portion  which  lies  next  to  the  intervertebral 
substances.  It  may  also  begin  in  the  intervertebral 
discs  themselves ;  but  wherever  its  precise  origin,  and 
whether  we  call  it  a  simple  caries  or  osteitis,  or  it  be 
of  a  distinctly  tuberculous  nature,  the  process  leads  to 
softening  and  crumbling  away  of  the  bone,  and  a 
collection  of  matter  is  formed  which  consists  of  broken- 
down  bone,  inflammatory  products,  and  pus,  and 
which  lies  in  front,  or  more  often  a  little  to  one  side 
of  the  fronts,  of  the  bodies.  The  position  of  the  abscess 
is  determined  by  the  seat  of  the  disease,  by  the  greater 
ease  with  which  pus  can  accumulate  in  front  than 
behind,  a  tendency,  moreover,  which  is  encouraged  by 
the  forward  bending  of  the  column.  By  gravitation 
the  pus  makes  its  way  downwards  along  the  front  of 
the  spine ;  the  abscess  assumes  a  pear  shape,  and 
according  to  the  site  of  the  disease,  and  the  rate  of 
increase,  will  be  the  exact  point  at  which  it  ultimately 
appears.  It  may,  however,  remain  limited  to  the 
seat  of  disease,  and  should  the  destructive  process 
cease  it  may  then  dry  up,  and  undergo  the  same  kinds 
of  changes  as  occur  in  old  abscesses  elsewhere.  We 
shall  return  to  the  consideration  of  the  abscesses 
when  we  have  dealt  with  the  various  symptoms  to 
which  Pott's  disease  may  give  rise,  and  by  Avhich  the 
surgeon  should,  if  possible,  diagnose  it  in  its  earliest 
stages,  before  the  diagnosis  has  been  made  for  him  by 
the  appearance  of  an  abscess  or  the  median  angular 
projection. 

£tiologry. — Injury  such  as  a  severe  spinal  bend 
or  wrench  may,  it  is  thought,  have  some  share  in 
starting  the  morbid  process,  by  bruising  an  inter- 
vertebral disc  or  stretching  the  anterior  common 
ligament ;  but  very  commonly  the  disease  seenis  to 
begin  wdthout  more  definite  causes  than  poor  living 
cc— 21 


434  Manual  of  Surgery. 

and  general  insanitary  conditions,  such  as  are  found 
amongst  the  children  of  the  poor.  These  causes  will 
naturally  be  more  potent  for  evil  in  children  of 
strumous  tendency,  hereditary  or  acquired. 

Symptoiiis. — Far  too  often  cases  of  Pott's  disease 
come  under  observation  only  when  the  mischief  has 
been  done,  and  the  story  is  told  of  past  ailment,  and 
that  the  child's  back  has  now  "  begun  to  grow  out." 
There  are,  however,  important  symptoms,  even  in  the 
period  of  indefinite  ailing,  wliich,  in  combination  with 
general  malaise  and  health  failure  in  children,  should 
make  the  surgeon  tolerably  certain  that  he  has  to 
deal  with  a  case  of  Pott's  disease. 

These  symptoms  are  spinal  stiffness  and  pain. 
The  spinal  stiffness  is  the  result  of  an  instinctive 
effort  on  the  part  of  the  spinal  muscles  and  liga- 
ments to  hold  the  column  rigid,  so  that  there  may 
be  no  movement  or  jarring  at  the  seat  of  disease. 
The  rigidity  can  easily  be  detected  by  careful 
observation  of  the  child's  movements  after  it  has 
been  stripped,  by  watching  how  it  will  stoop  to 
pick  things  up  from  the  floor,  how  it  will  turn  round 
in  bed,  or  how  the  back  comports  itself  when  the  child, 
flat  upon  its  face,  is  raised  up  by  tlie  pelvis  or  legs. 
It  is,  therefore,  very  necessary  to  be  familiar  with  the 
range  of  mobility  and  flexibility  of  the  healthy  spinal 
column,  both  in  children  and  adults.  In  severe  cases 
spinal  movement  is  pretty  sure  to  cause  pain,  which, 
however,  is  a  less  valuable  symptom  than  spinal 
rigidity,  for  tlie  inflammatory  mischief  is  far  from  the 
surface,  it  is  diflicult  for  a  child  to  localise  its  seat, 
and  spinal  pain  is,  moreover,  a  common  complaint  in 
other  and  less  important  maladies.  It  may  be  re- 
stricted to  the  seat  of  mischief,  or  in  cases  where  the 
inflammatory  action  involves  the  nerves  as  they  issue 
from  the  spine,  it  may  be  radiant  in  character  and 
far  removed  from  the  site  of  the  disease.     Absence  of 


Pott's  Disease.  435 

pain  is,  at  the  same  time,  very  common ;  and  it  is  by 
no  means  to  be  assumed  in  any  case  that  because  pain 
is  absent  there  is  therefore  no  disease.  The  important 
practical  point  for  the  surgeon  to  remember  is  this, 
that  in  all  cases  where  there  are  complaints  of  pain  in 
the  back,  or  pain  or  other  abnormal  sensations  in  any 
part  of  the  body  or  limbs  in  children,  for  which  no 
obvious  local  cause  is  discoverable,  he  should  make  it  his 
unfailing  business  to  examine  the  spine  to  see  whether 
there  be  any  rigidity,  for  this  is  a  symptom  rarely  or 
never  absent  even  in  the  very  earliest  stages  of  Pott's 
disease,  when  treatment  may  perchance  be  of  some 
avail  in  arresting  the  caries.  The  combination  of  the 
two  symptoms  is  an  almost  infallible  guide  to  the 
diagnosis  of  Pott's  disease. 

The  sjnnal  deformity,  or  median  angular  projection, 
is  due  to  the  destruction  of  the  bodies  already  named, 
and  is,  to  some  extent,  the  result  of  a  conservative 
process,  for  the  gap  in  the  bodies,  which  no  reparative 
process  can  fill  up,  is  nevertheless  obliterated  by  the 
falling  together  and  ultimate  union  of  the  healthy 
vertebrae  which  form  the  upper  and  lower  boundaries 
of  the  diseased  area.  When  the  destruction  is  rapid 
and  extensive  the  projection  may  become  well  marked, 
even  in  a  very  short  time,  while  in  others  the  rate  of 
its  formation  may  be  slow  ;  and  in  the  lumbar  region, 
where  the  bodies  are  large,  the  deformity  may  be  very 
slight  indeed.  It  is  usually  most  prominent  in  the 
dorsal  region,  in  consequence  of  the  length  of  the 
dorsal  spines.  It  may  be  sharp  and  abrupt,  or  little 
more  than  a  general  increase  in  the  natural  dorsal 
curve,  with  rather  undue  prominence  of  one  or  two 
spines.  Much  depends  on  the  rate  of  progress  and 
the  extent  of  the  disease.  When  the  projection  has 
existed  for  any  length  of  time,  and,  indeed,  while  it 
is  being  formed,  the  posterior  segments  of  the  vertebrae, 
the  spinous  and  transverse  processes,  the  laminae  and 


436  Manual  of  Surgery. 

ribs,  become  anchylosed  together  by  inflammatory 
adliesions,  whereby  strengthening  of  the  column  is 
effected.  The  fibrinous  material  thus  produced  may 
ultimately  ossify,  uniting  the  various  parts  into  one 
bony  mass.  Eigidity  is,  of  course,  a  marked  feature 
in  such  conditions,  and  the  wasting  of  the  spinal 
muscles  from  disuse  makes  the  angular  projection 
still  more  noticeable  than  it  would  otherwise  be.  The 
anterior  parts  may  also  become  consolidated  together  by 
thickening  of  periosteum  and  contraction  of  the  abscess 
cavity,  and  permanent  irremediable  deformity  is  the 
result.  At  the  same  time  the  patient  has  been  all 
along  endeavouring  to  keep  the  head  erect,  and  com- 
pensatory curves  are  formed  in  other  regions.  The 
sternum  gets  pushed  forwards,  the  shoulders  are  high 
with  the  head  sunk  between  them,  and  the  child  pre- 
sents an  aspect  strangely  old. 

There  are  three  chief  varieties  of  abscess  due  to 
Pott's  disease  :  psoas,  iliac,  and  lumbar. 

Psoas  abscess  is  the  commonest  of  them,  and 
is  so  named  from  its  position  in  the  sheath  of  the  psoas 
muscle.  It  may  be  regarded  as  an  almost  unfailing 
sign  of  Pott's  disease  in  the  dorsal  region,  although 
occasionally  it  may  be  met  with  as  the  result  of  disease 
lower  down.  Shaw  has  given  the  following  admirable 
account  of  its  formation  and  progress :  "  When  the 
abscess  is  connected  with  diseased  dorsal  vertebrae,  it 
encounters,  in  its  descent,  the  diaphragm.  But  that 
barrier  is  overcome  by  a  particular  process.  As  the 
abscess  comes  into  contact  with  the  diaphragm  and 
compresses  it,  adhesive  inflammation  is  set  up  in  their 
respective  surfaces;  the  consequence  is,  that  they 
become  united  over  a  considerable  area ;  an  opening  is 
next  formed  by  absorption  within  the  boundaries  of 
the  adhering  structures ;  the  abscess  then  protrudes ; 
and  extravasation  of  pus  at  the  margins  is  prevented 
fi-om    taking   place   by  the  firm  union  of  the  parts 


Psoas  Abscess.  437 

encircling  the  opening."  It  next  "  comes  into  relation 
with  the  heads  of  the  psoas  muscle ; "  but  as  it 
"  travels  downwards  it  has  to  pass  through  a  narrow 
strait ;  it  is  prevented  from  enlarging,  in  the  fore  part, 
by  the  resistance  of  the  ligamenta  arcuata,"  which 
stretch  across  the  two  origins  of  the  muscle,  "  and,  at 
the  back,  by  that  of  the  spine  and  lowest  rib ;  hence, 
in  order  to  proceed,  it  has  to  force  its  way  in  the  line 
of  the  psoas  muscle.  That,  however,  can  oiily  be  done 
by  penetrating  into  its  interior.  It  accomplishes  this, 
in  the  first  place,  by  inserting  its  most  advanced  part, 
like  a  wedge,  between  the  two  origins  ;  it  then  splits 
and  distends  the  fibres ;  and  the  psoas  at  length  is 
converted  into  an  abscess."  The  connections  of  the 
fascia  iliaca  being  looser  on  the  outer  than  the  inner 
side,  the  abscess  enlarges  most  freely  in  that  direction, 
and  now  cliiefly  occupies  the  hollow  between  the 
united  fibres  of  the  iliacus  internus  and  psoas  muscles 
on  the  inside,  and  the  crest  of  the  ilium  on  the  outside, 
When  the  advanced  part  reaches  Poupart's  ligament, 
a  certain  retardation  occurs ;  and  then  a  bulging 
will  be  observed  along  the  line  of  the  flexure  of  the 
groin. 

Pus  may  also  travel  below  Poupart's  ligament  as 
far  as  the  insertion  of  the  psoas,  and  form  there  a 
fluctuant  swelling,  the  size  of  which  may  be  modified 
both  by  position  and  pressure.  When  the  pus  has  in- 
creased so  much  that  there  is  a  distinct  swelling  both 
above  and  below  Poupart's  ligament,  the  diagnosis 
ought  to  be  a  matter  of  no  difiiculty,  for  pressure  at 
one  part  surely  causes  enlargement  of  swelling  at  the 
other.  Unlike  a  hernia,  therefore,  of  which  no  trace 
can  be  felt  in  the  abdomen  when  it  has  been  reduced,  a 
distinct  abdominal  swelling  can  still  be  detected  in  the 
region  of  the  psoas  when  the  abscess  is  made  solely  to 
occupy  a  position  above  the  groicu  Nor  is  an  abscess 
reducible   with   that   peculiar   gurgle   or   suddenness 


438  Manual  of  Surgery. 

which  often  characterises  the  reduction  of  a  hernia. 
Unlike  a  femoral  hernia,  a  psoas  abscess  lies  rather  to 
the  outer  side  of  the  femoral  vessels.  In  the  earlier 
stages  of  abscess  formation,  when  pus  at  first  distends 
the  sheath  of  the  psoas,  and  little  or  no  swelling  can 
be  felt,  the  presence  of  pus  can  only  be  suspected 
from  the  tendency  of  the  child  to  keep  its  thigh  flexed 
so  as  to  relieve  tension  on  the  muscle ;  and  should  this 
posture  lead  to  a  suspicion  of  hip  disease,  we  shall  find 
that  although  extension  may  cause  pain  in  the  psoas 
region,  yet,  nevertheless,  the  thigh  can  be  flexed  on 
the  pelvis  in  a  manner  singularly  different  from  the 
limitation  of  that  movement,  independent  of  move- 
ment of  the  pelvis,  which  is  so  striking  in  that 
disease. 

As  an  offshot  very  often  from  a  psoas  abscess, 
pus  may  come  to  lie  in  the  iliac  fossa^  or  it  may 
gravitate  there  from  disease  of  the  lumbar  bodies. 
When  very  large,  the  iliac  collection  of  pus  may  make 
its  way  over  the  crest  of  the  ilium,  appear  in  the 
gluteal  region,  and  seem  to  have  no  possible  connec- 
tion with  Pott's  disease.  Care  must,  therefore,  be  ex- 
ercised in  the  diagnosis  of  such  cases,  and  search  be 
made  for  the  real  cause,  as  also  in  cases  where  the 
pus  has  travelled  into  the  perinaium,  the  ischio-rectal 
fossa,  the  back  of  the  thigh,  or  other  unusual  sites. 
When  the  lumbar  vertebrae  are  affected,  it  is  common 
for  the  abscess  to  point  in  some  part  of  the  loin,  when 
it  is  known  as  lumbar  abscess.  It  makes  its  appear- 
ance on  the  surface,  often  as  a  square-shaped  swelling, 
to  the  outer  side  of  the  quadratus  lumborum,  between 
the  iliac  crest  and  the  last  rib ;  and  in  cases  where 
there  is  little  or  no  deformity,  as  may  happen  in  this 
region,  it  may  be  a  matter  of  some  doubt  whether  the 
abscess  is  really  due  to  Pott's  disease.  When,  how- 
ever, there  is  disease  in  the  dorsal  region,  and  there  is 
obvious  deformity,  rigidity,  or  pain,  and  the  abscess  is 


Pott's  Disease. 


439 


either  the  offshoot  of  a  psoas  abscess,  or  has  made  its 
way  to  the  loin  because  the  pus  could  not  overcome 
that  obstacle  to  its  descent  which  exists  at  the 
"narrow  strait"  described  by  Shaw,  there  is  little 
difficulty  in  associating  it  with  Pott's  disease.  In  all 
doubtful  cases,  whatever  may  be  the  site  of  the  ab- 
scess, the  spine  and  spinal  movements  must  be  care- 
fully examined,  for  local  or  general  rigidity,  even  if 
no  deformity  has  yet  arisen,  is  in 
such  cases  highly  suggestive  of 
this  disease. 

Di!!»tiirbaiicc  of  the  spi- 
nal cord. — A  remarkable  cir- 
cumstance in  connection  Avith 
Pott's  disease  is  the  rarity  with 
which  the  inflammatory  mischief 
spreads  to  the  spinal  canal,  and 
the  frequency  Asith  which  the 
cord  is  undamaged  even  when  it 
shares,  as  of  necessity  it  must 
share,  in  the  bend  to  which  the 
spine  is  subjected  in  the  course 
of  the  disease.  The  active  mis- 
chief, however,  is  usually  at  the 

front  of  the  bodies  away  from  the  spinal  canal,  and 
the  slow  rate  at  which  the  column  bends  allows  the 
cord  time  to  accommodate  itself  to  the  new  conditions 
under  which  it  is  placed. 

Unquestionable  disturbances  of  motion  and  sensa- 
tion, and  even  complete  paraplegia,  may  occasion- 
ally be  met  with,  and  form  distinct  evidences  that 
the  cord  or  nerves  have  been  somehow  implicated. 
Two  circumstances  seem  prone  to  contribute  to  this 
result :  disease  aflfecting  the  hinder  parts  of  the  bodies 
{see  Fig.  92)  and  very  rapid  formation  of  deformity 
from  rapidity  and  activity  of  the  disease. 

The  symptoms  rarely  indicate  complete  destruction 


Fig.  92.— Pott's  Disease 
involvinsr  the  posterior 
parts  of  the  vertebrae. 


440  Manual  of  Surgery. 

of  the  marrow,  and  such  as  there  are  are  rathei 
clue  to  pressure,  either  of  bone  or  inflammatory  pro- 
ducts, than  to  actual  myelitis.  Paralysis  of  bowel 
and  bladder  are  uncommon,  and  bed-sores  are  most 
rare.  Paralysis  of  motion  may  affect  single  muscles 
or  groups  of  muscles  with  the  same  nerve  supply, 
and  there  may  be  great  increase  of  reflex  irritability. 
Exaggeration  of  knee  jerk  and  ankle  clonus  are  often 
conspicuous  phenomena,  which  in  any  case  of  para- 
plegia should  suggest  an  examination  of  the  spinal 
column.  Disturbances  of  sensation,  hyperaesthesise  or 
peripheral  neuralgic  pains  are  also  not  uncommon. 
Let  their  presence  in  doubtful  cases  lead  to  examina- 
tion of  the  spine.  Whatever  may  be  the  nervous 
disturbance,  recovery  is  often  complete,  as  the  disease 
subsides  and  the  inflammatory  products  around  and 
about  the  neiwes  or  cord  undergo  absorption.  They 
add,  however,  to  the  gravity  and  anxiety  of  every  case, 
and  call  for  such  treatment  as  shall  best  arrest  the 
progress  of  the  disease. 

The  treatment  of  Pott's  disease  is  always 
a  matter  of  considerable  difficulty,  especially  amongst 
the  poor,  from  the  necessity  of  carrying  it  out  for  a 
very  long  time,  for  many  months,  or  even  years. 
Whatever  be  the  special  plan  adopted,  one  principle, 
and  one  only,  should  underlie  it,  and  that  is  to  secure 
rest  for  the  sj)inal  column. 

In  the  early  stages  of  the  malady,  when  its 
existence  has  been  determined  by  the  symptoms 
named,  before  deformity  exists,  whether  the  disease  is 
slow  or  acute,  or  whatever  its  site,  the  child  should 
be  kept  absolutely  at  rest  in  bed.  He  should  lie  on 
a  good  flat  mattress,  with  the  whole  spine,  from 
head  to  sacrum,  as  straight  as  possible  ;  and  if  needful 
this  end  must  be  secured  by  the  use  of  splints  to  the 
limbs,  or  other  means,  to  pi-event  movement.  The 
earlier  the  diagnosis  is  made,  the  greater  likelihood 


Pottos  Disease.  441 

is  there  that  simple  rest  in  bed  will  stay  the  dis- 
ease, and  so  obviate  the  permanent  deformity  which 
must  in  the  end  ensue.  Doubly  important,  therefore, 
is  early  diagnosis.  There  is  no  credit  in  making  a 
diagnosis  when  the  hump  is  already  there.  "When  the 
disease  has  gone  so  far  that  the  bodies  are  falling 
together,  their  friction  against  each  other  tends  to  set 
up  irritation  and  aggi'avation  of  the  disease,  and  it  is 
then  desirable  to  secure  fixation  of  the  spine  in  such 
a  position  of  slight  extension  of  the  column  that  the 
apposition  of  inflamed  parts  of  the  bodies  shall  be 
pre\ented. 

This  may  readily  be  accomplished  by  the  appli- 
cation of  a  Sayres  jacket  while  the  patient  is  in  the 
prone  position,  or  of  a  jacket  made  of  poroplastic  felt, 
resting  satisfied  with  that  amount  of  extension  which 
may  be  gained  by  simple  posture,  rather  than  by  forcible 
extension  to  run  the  risk  of  actually  fracturing  the 
spine.  The  jacket  often  gives  immense  relief  ;  and 
having  been  applied,  it  must  be  a  consideration  in 
every  case  whether  the  child  shall  be  allowed  to  run 
about  or  whether  it  shall  still  remain  in  bed.  Moving 
about  may  sometimes  be  advantageous  ;  in  any  case 
it  will  be  less  injurious  when  a  jacket  is  on  than  when 
the  spine  has  no  support ;  but  the  wearing  of  a  jacket 
should  never  be  the  excuse  for  letting  a  child  run  and 
play  as  if  nothing  were  the  matter  with  it.  liest  in 
the  recumbent  posture  should  at  any  rate  be  enforced 
for  many  hours  a  day. 

There  is  probably  no  kind  of  abscess  in  which  the 
beneficial  residts  of  early  opening  under  Listerian 
antiseptic  precautions  are  now  so  manifest,  as  formerly 
there  was  none  in  which  the  results  of  opening, 
spontaneous  or  by  the  knife,  were  in  the  pre-aseptic 
days  so  often  disastrous.  The  long  sinuous  cavity  of 
an  iliopsoas  abscess  provided  the  very  conditions  for 
the  origin  of  septicaemia  after  contamination  with  the 


442  Manual  of  Surgery. 

air,  and  the  opening  of  a  psoas  abscess  was  frequently 
tlie  beginning  of  a  so-called  "  hectic  fever,"  really  a 
sopticoemia,  ending  in  death.  Now  all  this  is  changed. 
In  his  description  of  the  opening  of  a  psoas  abscess 
above  Poupart's  ligament,  Mr.  Cheyne  says  that  "  there 
are  two  reasons  for  choosing  this  situation.  In  the 
first  place,  the  old  rule  that  these  abscesses  must  not 
be  opened  early  is  now  done  away  with,  and  under 
truly  aseptic  treatment,  as  soon  as  fluctuation  is 
detected,  an  operation  is  performed  of  a  similar  nature 
to  that  for  tying  the  external  iliac  artery,  and  the 
abscess  is  opened  after  a  careful  dissection.  The 
sooner  the  abscess  is  opened  the  better,  for  the  abscess 
cavity  is  thus  smaller  than  if  the  surgeon  waits  till 
the  pus  has  burrowed  its  way  into  the  thigh ;  and, 
further,  so  long  as  the  pus  is  there  it  irritates  by  its 
tension,  and  thus  keeps  up  the  chronic  inflammation 
in  the  spine.  Another  reason  is,  that  it  ought  to  be 
opened  as  far  as  possible  from  sources  of  putrefaction."* 
The  same  principle  of  treatment  must  be  applied  to 
lumbar  abscesses  ;  while  for  abscesses  connected  with 
the  twelfth  dorsal  and  lumbar  vertebrse  Mr.  Treves 
has  proposed  to  reach  the  seat  of  the  disease,  and  drain 
the  cavity  by  a  carefully-planned  dependent  opening  in 
the  loin.t  In  one  case  thus  treated  by  him  a  large 
sequestrum  was  removed.  A  dependent  opening  for 
the  evacuation  of  ilio- psoas  abscess  has  also  been 
obtained  by  trephining  the  ilium. 

Disease  op  the  Cervical  Spine. 

It  remains  for  us  to  consider  those  cases  where 
Pott's  disease,  similar  in  all  probability,  both  in 
cause  and  pathology,  to  that  met  with  in  the  rest  of 
the  spine,  involves  vertebrae  in  the  cervical  region. 
The    cervical    vertebrae     differ    so    much    in    shape 

•  **  Antiseptic  Treatment  of  "Wounds,"  p.  84, 
t  Medico  Chir.  Trans.,  vol.  btviL 


Cervical  Caries.  443 

and  size  from  those  in  other  parts  that  disease 
in  this  region  is  more  prone  to  light  up  in  inflam- 
matory mischief  about  the  meninges  or  cord.  In 
the  region  of  the  atlas  and  axis  it  is  very  prone  also 
to  involve  the  joints  between  these  two  bones,  and 
less  commonly  those  between  the  occiput  and  atlas. 
The  transverse,  odontoid  and  other  ligaments  also  are 
frequently  softened  or  destroyed,  and  slipping  forward 
of  the  atlas  upon  the  axis  is  the  usual  result,  with 
narrowing  of  the  spinal  canal  and  pressure  of  the 
cord  against  the  odontoid  process.  Sudden  death  is 
therefore  always  to  be  feared  when  there  is  disease  in 
this  region,  and  treatment  must  ensure  the  most 
perfect  immobility  of  the  head  and  neck. 

The  sjTiiptoins  of  cervical  caries  are  of  the  same 
nature  as  when  the  disease  is  in  other  parts. 

Pain  is  more  common  and  often  more  definite 
than  in  Pott's  disease  in  the  dorsal  region,  and  may 
definitely  follow  the  course  of  one  of  the  sensory 
branches  of  the  upper  cervical  nerves,  which  issue 
from  the  spine  in  such  close  proximity  to  the  disease. 
As  Hilton  pointed  out,  the  jDain  is  frequently 
unilateral.  Severe  neuralgic  pain,  therefore,  increased 
by  pressure  on  the  head  or  neck,  or  by  any  sudden 
movement  of  either,  in  the  course  of  the  cervical 
nerves,  the  great  and  small  occipital,  the  great  auri- 
cular and  superficialis  colli,  or  the  sternal,  clavicular, 
and  acromial  nerves,  associated  with  rigidity  of  any  of 
the  muscles  of  the  neck,  especially  the  trapezii,  should 
never  fail  to  raise  the  suspicion  of  vertebral  disease. 

"  Rigidity  of  the  trapezii,"  Owen  says,  "  when 
associated  with  stifi"  neck^  is  almost  pathognomonic 
of  inflammation  in  the  cervical  spine;"  and  when 
to  this  sign  is  added  "neuralgic  headache,"  there 
ought  to  be  little  difiiculty  in  arriving  at  an  accurate 
diagnosis,  and  the  error  should  be  avoided  of  looking 
on  the  case  as  one  merely  of  "  rheumatism  "  or  stiff 


444  Manual  of  Surgery, 

neck.  The  same  kind  of  neuralgic  pain  may  be  felt 
in  the  periphery  of  branches  of  the  brachial  plexus 
when  disease  is  in  the  lower  cervical  region. 

Deformity  is  not  so  marked  in  the  neck  as  elsewhere, 
because  the  smallness  of  the  parts  destroyed  makes 
angular  projection  an  improbable  result.  In  atlo- 
axoid  disease  the  head  is  poked  forwards,  from  the 
slipping  forward  of  the  first  upon  the  second  vertebra. 
The  chin  points  downwards,  and  perhaps  one  or  more 
of  the  spinous  processes  become  unduly  prominent. 
Compensatory  curves  are  established  in  other  regions 
to  remedy  this  position  when  the  disease  has  been 
arrested  and  there  is  permanent  rigidity. 

Swelling  makes  its  appearance  pretty  soon  from 
inflammatory  exudation  into  the  soft  tissues,  and 
there  may  be  distinct  fluctuation  and  abscess  in  the 
suboccipital  region.  Oftener,  however,  the  pus 
travels  far  from  the  original  seat  of  the  disease,  and, 
guided  by  the  fasciae  around  the  muscles,  and  by  gravi- 
tation, may  appear  in  the  posterior  triangle,  in  front 
of  the  trapezius,  or  near  the  posterior  border  of  the 
sterno-mastoid  muscle.  When  the  disease  is  strictly 
confined  to  the  anterior  parts  of  the  vertebra,  abscess 
may  point  in  the  posterior  wall  of  the  pharynx,  where 
it  may  even  burst  and  cause  death  by  sufibcation. 
The  same  line  of  treatment  must  be  followed  in  the 
case  of  cervical  abscesses  as  in  other  regions ;  while  the 
difiiculty  of  emptying  and  draining  a  post-pharyngeal 
abscess  antiseptically  may  be  overcome  successfully  by 
burrowing  down  to  it  from  an  opening  in  the  side  of 
the  neck  behind  the  sterno-mastoid.  Absolute  rest 
is  ao:ain  essential  in  all  these  cases.  In  atlo-axoid 
disease  the  patient  must  lie  perfectly  flat  upon  his 
back,  and,  as  recommended  by  Hilton,  the  neck  must 
be  supported  by  a  small  firm  pad  to  fill  up  the  sub- 
occipital fossa,  while  the  occiput  itself  rests  on  a 
cushion  or  circular  pad.     Tilting  forward  of  the  atlas  is 


Spondylitis  Deformans.  445 

thus  prevented^  and  the  cord  is  relieved  from  pressure. 
Immobility  must  be  secured  by  sand-bags  on  each  side 
of  the  head  or  neck,  or  by  fixing  the  head  with 
bandages.  And  thus  the  patient  must  lie,  with  head 
and  neck  immobile  for,  it  may  be,  many  months ;  and 
not  until  all  active  mischief  has  subsided  and  anchy- 
losis has  occurred  should  there  be  any  experiments  in 
moving  the  head.  When  disease  involves  the  lower 
cervical  vertebrre  the  head  must  be  supported  and  the 
neck  fixed  by  a  cervical  collar.  The  necessity  for 
absolute  rest  in  bed  must  be  determined  by  the  acti^dty 
and  extent  of  the  disease. 

Pott's  disease  in  adults. — Pott's  disease  is 
most  commonly  met  with  in  early  life ;  but  it  may  be 
seen  in  adults,  and  follow  precisely  the  same  course, 
with  a  tendency  very  often  to  be  more  rapid  in  pro- 
gress than  it  is  in  children.  In  adults  it  may  be  due 
to  syphilis,  and  in  the  cervical  region  may  be  set  up 
by  syphilitic  ulceration  in  the  posterior  wall  of  the 
pharynx.  Constitutional  treatment  must  clearly  be 
directed  to  this  special  malady,  in  addition  to  local 
measures  for  securing  rest. 

Spondylitis  deformans  is  the  name  given  to 
a  disease  which  affects  the  vertebral  column,  and  is  the 
same,  or  of  the  same  nature,  as  that  termed  "  chronic 
rheumatic  arthritis  "  when  affecting  other  parts.  As 
a  consequence  of  absorption  of  the  articular  cartilages 
and  of  the  intervertebral  discs,  and  the  develop- 
ment of  osteophytic  prominences  from  the  edges  of 
the  vertebral  bodies,  and  ossification  of  the  ligaments, 
especially  the  anterior  common  ligament,  the  spine 
becomes  bent  and  rigid,  and  a  very  characteristic 
deformity  is  the  result. 

Symptoms. — Cyphosis  is  produced,  and  as  the 
disease  frequently  affects  the  whole  or  major  part 
of  the  column,  there  is  one  long  antero-posterior 
curve,  the  patient  has  a  constant  stoop,  his  stature  is 


446  Manual  of  Surgery. 

diminished,  tliere  is  complete  rigidity  of  his  spine, 
and  his  movements  are  awkward  and  constrained. 
In  lesser  grades  of  the  disease  the  cervico-dorsal  or 
the  lumbo-dorsal  regions  may  be  alone  affected,  and 
the  signs  are  less  pronounced.  With  advance  of  the 
disease  the  spinal  muscles  waste,  and  the  curvature 
becomes  more  prominent,  the  head  is  poked  forwards, 
the  shoulders  appear  unusually  round,  and  the  patient 
is  obliged  to  support  himself  with  a  stick. 

Spondylitis  deformans,  sometimes  called  "  syn- 
ostosis of  vertebrae,"  is  commonly  a  disease  of  later 
middle  and  advanced  life,  is  seen  more  often  in  men 
than  in  women,  and  is,  perhaps,  determined  to  some 
extent  by  occupations  which  involve  long  stooping  at 
work.  It  is  generally  associated  with  evidences  of 
rheumatoid  disease  in  other  parts  of  the  body.  Rarely 
it  is  met  with  earlier  in  life,  when  in  all  probability 
the  combined  effects  of  heredity,  and  of  those  some- 
what indefinite  conditions,  cold,  exposure,  lack  of  food, 
which  may  be  supposed  to  excite  and  further  the  de- 
velopment of  any  inherited  malady,  have  lighted  up  the 
disease.  In  such  cases  it  may  happen  that  every  joint 
of  the  spinal  column  may  become  involved,  and  the 
term  "  intervertebral  arthritis  "  may  fitly  be  applied 
to  them.  The  suffering  may  be  extreme,  and  the  ten- 
dency is  to  early  death  from  exhaustion  and  pain.  In 
the  chronic  cases  of  older  people,  however,  there  may 
be  neither  pain  nor  much  obvious  interference  with 
the  general  health,  and  the  patient  may  live  for  years. 

No  known  treatment  has  any  influence  on  this 
obscure  and  little  understood  disease.  It  seems  pro- 
bable that  in  some  cases  the  disease  has  been  started 
in  connection  with  gonori'hoea,  a  sort  of  "  gonor- 
rhoeal  rheumatism  ; "  but  if  on  this  point  there  be 
doubt,  there  is  none  as  to  its  having  become  worse 
during  an  attack  of  specific  urethritis.  Much  has  yet 
.to  be  done  in  elucidation  of  this  strange  malady. 


447 


X,     INJURIES    OF   THE    SPINE. 

Herbert  W.  Paob. 

Contusions  and  contused  "ivounds  of  the 
back  do  not  differ  in  tlie  main  from  the  same  kinds  of 
injury  in  other  parts.  The  thickness,  however,  of  the 
skin  of  the  back  prevents  it  from  giving  way  even 
after  considerable  violence,  and  extensive  subcutaneous 
extravasation  of  blood  (hsematoma)  may  be  met  with, 
which  undergoes  absorption  in  the  usual  way.  As 
the  result  of  any  severe  injury  of  the  kind,  stiffness  of 
the  back  is  not  improbable  from  damage  to  some  of  the 
spinal  muscles. 

The  treatment  of  this  condition  will  be  considered 
when  we  come  to  speak  of  spinal  sprains. 

In  cases  of  severe  contusion  in  the  lumbar  region, 
even  without  external  mark  or  laceration  of  skin,  it 
may  happen  that  hsematuria  soon  shows  itself  after  the 
accident,  owing  to  damage  to  the  kidney.  The 
symptom  is  not  by  itself  alarming,  and  it  is  very  rare 
for  hsemon'hage  to  be  fatal  from  this  cause.  Nay,  the 
tendency  is  rather  for  the  bleeding  to  cease  sponta- 
neously in  the  course  of  a  few  days.  [See  Art.  xii., 
vol.  iii.) 

Punctured  or  incised  wounds  of  the  back 
may  cause  gi-ave  injury.  The  horizontal  direction  of 
the  spinous  and  transverse  processes  in  the  neck 
renders  it  by  no  means  difficult  for  any  long,  sharp, 
narrow  instrument  to  penetrate  the  spinal  canal,  and 
so  wound  the  spinal  membranes,  wound  or  sever  one 
or  more  of  the  spinal  nerves,  or  even  the  spinal  cord 
itself.  The  same  calamity  may  also  happen  lower 
down. 


44^  Manual  of  Surgery. 

The  diagnosis  of  simple  puncture  of  the  sj)inal 
canal  can  only  be  a  matter  of  certainty  when  there 
is  escape  of  cerebro-spinal  fluid,  and  by  an  accurate 
knowledge  of  the  direction  of  the  wound  and  the 
form  of  the  weapon  which  inflicted  it. 

Symptoms. — Injury  to  spinal  membranes  alone  in 
such  a  wound  may  cause  no  immediate  symptoms,  but 
there  is  great  risk  of  acute  inflammation  or  meningitis. 
The  symptoms  now  are  well  marked  and,  in  varying 
proportions,  consist  of  pain  and  tenderness,  spinal 
rigidity,  and  dread  of  being  jarred  or  moved,  pain  or 
hyperaesthesia  in  the  periphery  of  the  nerves  which 
have  origin  at  the  site  of  the  inflammation,  impair- 
ment of  motion  and  sensation,  rapidly  passing,  it  may 
be,  into  complete  paralysis  in  the  parts  below  should 
the  cord  itself  become  involved  in  inflammation,  a 
tendency  to  opisthotonos,  high  temperature,  rapid 
wasting,  vomiting,  and  general  unrest. 

The  prognosis  is  extremely  grave.  Great  also 
is  the  danger  if  the  cord  itself  has  been  injured,  a  fact 
which  may  be  told  by  the  existence  of  paralysis,  of 
interference  with  and  perversion  of  motion  or  sensation, 
or  of  both  combined,  over  a  limited  area,  or  universal 
in  the  parts  below  the  seat  of  injury,  according  to  the 
site  and  extent  of  the  wound,  changes  in  the  reflexeSi 
and  alteration  in  temperature  in  peripheral  parts : 
phenomena  indicative  of  disturbance  in  the  conducting 
paths  and  central  functions  of  the  cord.  Even  if  the 
external  wound  and  that  of  the  spinal  canal  be  closed, 
and  meningitis  has  been  escaped,  complete  recovery  is 
in  such  cases  rare,  for  union  and  repair  of  any  wound 
in  the  cord  are  both  uncertain  and  imperfect.  Some 
paralysis  is  too  likely  to  be  permanent,  and  secondary 
degeneration  in  the  cord  may  induce  other  and  later 
symptoms  of  nervous  disturbance. 

Treatment. — The  surgeon  must  make  it  his  first 
care  to  ensure  the  perfect  asepticity  and  early  closure 


SpRAjys  OF  THE  Back.  449 

of  the  wound,  and  the  spine  must  be  kept  absolutely 
at  rest.  Meningitis  is  the  immediate  danger  to  be 
feared,  and  it  may  be  well  to  begin  at  once  with 
the  administration  of  mercury  or  ergot,  or  of  both 
combined,  in  the  hope  of  controlling  the  tendency  to 
inflannnation  in  the  meninges  and  cord. 

Sprains  of  the  back  and  jspinc  are  extremely 
common,  and  often  troublesome.  They  do  not  differ, 
either  in  cause  or  pathology,  from  sprains  elsewhere ; 
but  the  fact  that  the  spinal  column  consists  of  many 
separate  bones  connected  together  by  an  almost  in- 
calculable number  of  ligamentous  and  muscular 
fibres,  many  of  them  deeply  seated,  and  that  it  has 
also  in  its  constitution  a  large  number  of  joints,  ren- 
ders the  symptoms  of  vertebral  sprains,  and  their  con- 
sequences, prone  to  last  longer,  to  cause  more  sutfeiing, 
and  to  be  more  obscure  than  like  injuries  elsewhere. 

The  most  flexible  parts,  the  cervical,  cervico-dor- 
sal,  and  dorso-lumbar  regions,  are  the  most  liable  to 
sprain,  the  stretching,  partial  rupture,  or  laceration, 
of  muscular  and  ligamentous  structures  being  fre- 
quently the  result  of  violence,  which  has  led  to  the 
spine  being  inordinately  bent,  or  because  they  have 
given  way  in  an  unwonted  muscular  effort ;  as  when 
a  man,  in  lifting  a  heavy  weight,  ruptures  some  fibres 
of  one  or  both  of  the  erectors  of  his  spine.  There  is, 
of  course,  an  infinite  variety  in  the  degree  of  this 
form  of  spinal  injury,  and  it  is  simply  a  question  of 
degree  whether  the  damage  affects  only  extraspinal 
structures  which  hold  the  segments  of  the  column 
together,  or  whether  the  more  important  intraspinal 
organs  have  been  injured  because  of  more  complete 
separation  of  those  segments  as  occurs  in  fracture- 
dislocation. 

Symptoms. — Be  the  cause  what  it  may,  and  in 
whatever  region,  the  symptoms  of  s}»inal  sprain  are 
such  as  are  seen  after  sprains  of  the  limbs,  viz.   local 

D  D— 21 


45 o  Manual  of  Surgery. 

pain  and  local  tenderness,  and  in  some  cases  sliglit 
local  swelling,  with  stiffness  and  rigidity  of  the 
affected  part. 

After  bad  lumbar  si)rain,  which  may  be  termed 
traumatic  lumhago^  it  is  not  unusual,  as  in  cases 
of  simple  lumbago  from  cold,  for  the  patient  to  feel 
much  difficulty  in  walking  ;  and  a  state  of  pseudo- 
paralysis of  the  legs  may  be  induced,  simply  from  stiff- 
ness and  incapacity  of  the  spinal  muscles,  which  no 
longer  give  natural  support  to  the  spine,  or  which  can- 
not be  called  into  action  without  pain.  The  patient 
complains,  and  may  fully  believe,  that  he  cannot  move 
his  legs  ;  but  careful  inquiry  will  elicit  that  he  is  really 
afraid  to  move  them  because  of  pain.  Difficulty  in 
defsecation  and  micturition,  and  inability  to  completely 
empty  the  bladder,  or  even  retention  of  urine,  may 
arise  from  the  same  muscular  incapacity.  Tlie  com- 
bination of  such  symptoms,  spinal  pain  and  stiffness, 
difficulty  in  walking,  and  interference  with  the  natural 
acts  of  defsecation  and  micturition,  may  suggest  veiy 
grave  inferences  that  the  injury  has  indeed  been  more 
serious  than  it  really  is,  and  has  even  involved  the 
spinal  cord. 

An  accurate  diagnosis  must  be  sought  in  the 
history  of  the  injury,  in  the  existence  of  local  aching 
and  stiffness,  and  in  observing  the  time  of  onset  of  these 
seemingly  paralytic  symptoms.  In  cases  of  real  intra- 
spinal injury,  paralytic  symptoms  are  much  more 
likely  to  be  found  immediately  after  the  accident, 
while  after  simple  spi'ain  they  may  be  entirely  absent 
until  the  stiffness  and  pain  become  pronounced,  as 
they  usually  do  in  the  course  of  a  few  days.  Where 
certain  diagnosis  is  impossible,  it  is  better  to  err  on 
the  side  of  assuming  central  injury,  than  of  failing  to 
recognise  it.  For  here  arises  a  dilemma,  that  the 
later  treatment  of  spinal  sprain  is  that  which  we 
ought   especially  to  avoid,  were  it  known  that  there 


Sprains  oh  the  Back.  451 

was  iiijury  to  the  spinal  membranes  or  the  cord. 
This,  unquestionably,  is  movement,  systematically 
carried  out  so  as  to  lessen  the  stiffness  and  its 
attendant  pain. 

Treatment. — As  in  the  treatment  of  sprains  else- 
where, so  also  is  it  in  the  case  of  the  sj)ine,  'movement 
must  be  begun  as  soon  as  by  rest  in  bed  and  the 
application  of  warmth  with  hot  flannels  or  linseed 
poultices,  the  pain  has  been  allayed,  the  tendency  to 
inflammation  has  been  kept  in  bounds,  and  nature  has 
set  about  the  work  of  repair.  No  precise  rules  can 
be  laid  down  as  to  the  lenojth  of  time  durinc;  which 
rest  must  be  enforced.  The  constipation  may  be 
relieved  by  aperients  or  simple  enemata,  and  any 
difhculty  with  tlie  bladder  may  be  relieved  by  the  use 
of  a  soft  catheter  scrupulously  clean.  These  early 
troubles  having  been  met,  we  must  have  the  patient 
out  of  bed,  so  that  by  the  movements  of  walking  and 
gentle  gymnastic  exercise  the  stiffness  and  pain  may 
be  removed.  Towards  this  end  massage  of  the  affected 
muscles  may  sometimes  be  of  great  service.  The 
symptoms,  aching  and  stiffness,  are  often,  however,  of 
long  continuance,  and  it  is  frequently  difficult  to  carry 
out  the  requisite  treatment  in  consequence  of  the 
pain  which  movement  entails.  Movement  and  the 
application  of  heat  may  be  beneficially  combined  by 
ironing  the  back  with  a  hot  iron,  for  the  heat  comj^els 
the  patient  to  move,  and  so  call  fibres  into  action  over 
which  he  has  no  voluntary  control.  The  pain  and 
stiffness  are  most  liable  to  last  for  a  long  time  in  those 
who  lead  a  sedentary  life,  a  fact  which  shews  the 
value  of  movement,  and  in  those  also  wlio  have  a 
tendency  to  gout  or  rheumatism.  In  such  Ciises,  in 
addition  to  constitutional  treatment,  the  occasional 
a})plication  of  the  combined  faradic  and  galvanic 
currents  to  the  affected  muscles  will  sometimes  give 
relief  when  other  means  have  failed. 


452  Manual  of  Surgerv, 

It  is  a  question  how  far  in  some  of  these  cases  the 
continuance  of  the  pain  and  stiffness,  when  dehnitely 
local  and  perhaps  unilateral,  may  be  due  to  a  more 
direct  involvement  of,  and  effusion  into,  one  or  more 
of  the  spinal  joints.  In  rare  instances  supjjuratioji  in 
a  joint  has  followed  severe  spinal  sprain,  and  it  may 
be  that  simple  effusion  at  times  occui-s  and  gives  rise 
to  the  same  sorts  of  symptoms  as  effusion  in  the  joints 
of  the  limbs. 

The  spinal  injuries  of  rail^vay  collisions 
are  essentially  of  the  same  kind  as  those  w^iich  have 
been  already  described,  and  are  very  common  after  such 
forms  of  accident,  because  the  violence  is  exactly  such 
as  to  cause  undue  bending  of  the  spinal  column,  or 
strain  of  muscular  fibres  when  the  patient  is  un- 
consciously holding  his  body  stiff,  as  an  involuntary 
means  of  protecting  himself  from  injury.  This  form  of 
spinal  injury  is  often  more  severe  in  what  may  be  called 
slight  collisions,  for  then  it  is  that  the  patient  is  likely 
to  be  thrown  to  and  fro  several  times  in  the  carriage,  a 
result  which  does  not  happen  in  the  severest  accidents, 
when  all  is  over  in  some  sudden  crash,  destructive  to 
the  carriages,  and  frequently  to  life  and  limb.  The 
spinal  sprains  thus  received  are  of  every  variety  and 
degree,  and  cases  are  sometimes  observed  where  the 
whole  vertebral  column  seems  to  have  been  sprained, 
is  painful  and  tender  throughout  its  whole  length,  and 
the  least  movement  is  for  a  time  well-nigh  impossible. 
Then  especially  is  it  tliat  the  existence  of  pseudo- 
paralytic symptoms  is  likely  to  cause  difficulty  and 
trouble,  for  it  rarely  happens  that  spinal  sprain  is  the 
sole  injury  sustained. 

Symjytom^. — As  a  consequence,  to  some  extent, 
of  the  general  violence,  but  more  especially  of 
the  alarming  circumstances  of  the  accident,  the 
patient  is  prone  to  suffer  from  a  train  of  symptoms 
which   have  their  beginning  in   undoubted    collapse, 


RAfFJVAv  SrrxE.  453 

which  do  not,  however,  pass  away  like  the  usual  symp- 
toms of  shock  after  otlier  and  commoner  injuries,  but 
may  be  protracted  and  little  amenable  to  treatment. 
As  the  result  of  the  shock,  of  shock  which  is  largely  if 
not  entirely  due  to  fright,  there  is  developed  a  con- 
dition of  general  bodily  and  mental  depression,  a  state 
of  neurasthenia,  or  nerve  weakness  and  exhaustion, 
which  is  not  dependent  on  any  kno^vn  structural 
changes,  and  which  may  even  arise  in  those  who  have 
met  with  no  bodily  injury  at  all. 

This  state  of  neurasthenia  is  characterised  by 
various  symptoms,  of  which  derangements  of  the  cir- 
culatory and  vaso-motor  systems  are  the  most  pro- 
nounced ;  and  we  meet  with  palpitation,  alternate 
sensations  of  heat  and  cold,  coldness  of  the  extremities, 
sweating,  diarrhoea,  menorrhagia,  and  sometimes  poly- 
uria, together  Avith  great  restlessness,  sleeplessness, 
and  nervousness,  as  marked,  perhaps,  in  males  as  in 
females,  loss  of  control  over  the  emotions,  a  tendency 
to  hysterical  crying,  asthenopia  from  weakness  of 
accommodation,  suppression  of  the  catamenia,  great 
languor,  and  early  fatigue  and  exhaustion  after  any 
physical  or  mental  work.  The  whole  condition,  wliich 
varies  much  in  indi\T.dual  cases,  may  be  summed  up 
in  the  one  word  neurasthenia,  which  indicates  that 
something  has  occurred  to  depress  and  lower  the  tone, 
vitality,  and  function  of  tlie  whole  nervous  system, 
cerebral,  spinal,  and  sympathetic. 

The  nervousness  and  depression  may  be  extreme, 
despondency  is  a  necessary  part  of  the  condition, 
and  the  patient  is  prone  to  give  way  to  his 
feelings.  In  this  state  of  neurasthenia  it  is  that 
the  pseudo-paralytic  symptoms  of  spinal  sprain  are 
likely  to  be  regarded  as  of  more  serious  moment  than 
they  really  are,  and  to  suggest  that  there  has  been  in- 
jury to  some  parts  of  the  central  nervous  system. 
These  cases  of  railway  injury  are  likely  to  make  large 


454  Manual  of  Surgery. 

calls  on  the  good  judgment  and  tact  of  the  surgeon, 
for  unfortunately  the  patient  is  sulyected  to  influences 
Avhich  may  seriously  retard  his  progress  towards 
recovery.  Prospective  compensation  may  tempt  him 
to  fraud  and  exaggeration,  or  may  quite  unconsciously 
prevent  any  voluntary  effort  being  made  to  throw  off 
the  invalid  state,  which  is  the  first  necessary  step  in 
the  return  to  work  and  a  healthy  mode  of  life.  The 
worries  of  litigation  are  also  seriously  opposed  to 
convalescence. 

Treatment. — Rest  both  of  body  and  mind  is  essen- 
tial in  the  treatment  of  such  cases,  and  it  must  be 
begun  soon.  Rest,  good  food,  fresh  air,  must  supply 
the  chief  means  of  treatment,  for  no  drug  has  any 
special  influence  over  this  state  of  neurasthenia,  un- 
less, indeed,  it  be  bromide  of  potassium,  which,  from 
its  powerful  depressant  action,  has  a  serious  tendency 
to  aggravate  the  symptoms  which  already  exist,  and 
to  develop  others  of  a  like  kind.  In  the  great 
inajoiity  of  cases  recovery  is  complete,  but  in  a  small 
proportion  of  the  severer  cases  the  patients  never 
seem  to  regain  the  same  strength  as  they  had 
before  the  accident,  or  do  so  only  after  a  very  long 
time. 

Meiiin§^tis  is  a  result  to  be  feared  in  all  cases  of 
severe  spinal  sprain.  There  are  two  forms  of  inflam- 
mation of  the  spinal  membranes,  the  acute  and  the 
chronic.  To  the  former  we  have  already  referred  in 
speaking  of  wounds  of  the  spinal  canal,  from  which 
this  kind  of  meningitis  usually  starts.  It  may,  how- 
ever, arise  when  there  has  been  no  wound,  either  from 
septic  poisoning,  or  some  ill  condition  of  the  patient 
causing  suppuration  at  the  seat  of  injury,  in  connection, 
it  may  be,  with  some  inflamed  intervertebral  joint. 
Suppuration  spreads  to  the  spinal  canal,  and  lights  up 
an  acute  meningitis  which  may  speedily  be  fatal ;  and 
after  death  the  spinal  membranes  are  found   batlied 


Spinal  Meningitis.  455 

in  pus,  and  here  and  there,  perhaps,  the  cord  itself  is 
softened  and  inflamed. 

Subacute  or  chronic  meningitis  runs  no  such 
violent  course,  but  is  most  insidious  both  in  its  origin 
and  progress.  Although  extremely  rare,  it  is  never- 
theless a  result  to  be  feared  when  the  sprain  has  been 
severe,  and  especially  in  the  flexible  cervical  spine. 
From  laceration  or  rupture  of  an  intervertebral  liga- 
ment, one  of  the  ligamenta  subflava  for  example,  there 
starts  an  inflammation  which  may  spread  inwards,  un- 
til inflammatory  lymph  is  poured  out  upon  the  spinal 
membranes,  glueing  them  together,  and  by  pressure 
implicating  either  the  spinal  nerves  or  the  spinal  cord. 
There  is  thus  developed  a  local  meningitis,  which  of 
itself  causes,  perhaps,  no  symptoms,  and  has  never  been 
suspected  until  some  nervous  structures  have  become 
involved,  when  the  real  mischief  has  then  been  done. 
Persistent  local  pain  and  local  tenderness,  increased  by 
pressure  or  movement,  more  especially  in  the  cervical 
region,  should  always  arouse  a  suspicion  of  the  exist- 
ence of  some  dee}>seated  inflammatory  mischief,  and 
enjoin  the  necessity  of  absolute  rest. 

When  the  meningitis  ("  pachymeningitis,"  as  it 
has  been  termed)  has  involved  nervous  elements,  cord 
or  nerve  roots,  other  signs  and  symptoms  help  to  make 
the  diagnosis  certain.  We  now  find,  in  varying  pro- 
portion and  degree,  interference  with  motion  and 
sensation  in  the  regions  supplied  by  individual  nerves, 
wasting  of  muscles,  peripheral  pains  and  other  evi- 
dences of  nerve  disturbance. 

Treatmerd  is  in  such  cases  far  from  satisfactory. 
Counter-irritation  should  be  used,  either  by  repeated 
blisters  to  the  spine,  or  by  seton  ;  and  the  persistent 
administration  of  mercury  and  iodide  of  potassium 
should  not  be  withheld,  even  in  cases  where  no 
syphilitic  element  is  present. 

Intraspinal  hseuioi-iiia^c  is  a  yet  rarer  result 


456  Manual  of  Surgery. 

than  the  foregoing  of  any  violent  twist  or  wrench  of 
the  spme,  and  is  due  to  some  vessel  giving  way  with- 
in the  sj)inal  canal.  The  quantity  of  extravasated 
blood  may  be  very  large,  and  give  rise  to  symptoms 
which  are  dependent  on  pressure  upon  the  spinal  cord. 
Paralysis  may  be  com})lete  of  all  tlie  parts  below  the 
blood  level,  which,  as  it  rises  in  the  canal,  may 
speedily  cause  death  from  interference  with  respiration. 
Intraspinal  htemorrhage  may  also  result  from  falls  on 
the  buttock,  or  from  severe  blows  on  the  spine ;  but 
from  any  cause  it  is  extremely  rare  unless  accom- 
])anied  with  other  injuries  to  the  spinal  column,  such 
as  fracture-dislocation. 

Symptoms. — It  maybe  difficult  to  say  whether  the 
sym2:>toms  are  really  due  to  haemorrhage  or  to  some 
more  immediate  damage  to  the  cord ;  but  in  the  latter 
case  the  })araplegia  is  commonly  instantaneous,  while 
from  hajmorrliage  the  symptoms  may  begin  to  show 
themselves  only  after  lapse  of  time,  or  they  may  steadily 
increase  as  the  blood  is  being  poured  out  in  the  canal. 
Should  the  Ijlood  be  small  in  quantity  and  low  down 
in  the  canal,  there  may  be  few  symptoms,  and  there 
is  hope  of  its  complete  absorption  and  of  ultimate 
recovery ;  but  there  is  also  a  risk  of  inflammatory 
mischief,  and  the  development  of  symptoms  which  are 
due  either  to  tlie  pressure  of  unabsorbed  clot,  or  of 
subacute  meningitis. 

Treatment. — Ice  must  be  applied  to  the  spine, 
whilst  the  patient  is  kept  at  perfect  rest  on  his  face, 
and  ergot  or  gallic  acid  should  be  administered.  In 
the  later  stages  we  must  follow  the  same  line  of  treat- 
ment as  in  subacute  meningitis.  It  is,  however,  but 
little  amenable  to  treatment,  both  in  its  actual 
progress  and  in  the  after-consequences  which  may 
ensue. 

A  very  rare  result  of  violent  and  extreme  bend  of 
the  spine  is  hajmorrhage  into  the  substance  of  the  cox'd 


Fractures  of  the  Spine.  457 

itself,  with  such  symptoms  as  must  necessarily  follow 
its  partial  or  complete  destruction  at  the  seat  of 
lesion. 

Fractures  and  Dislocations. 

Injuries  of  this  nature  are  most  commonly  caused 
hy  indii'ect  \T.olence,  whereby  the  spinal  column  has 
been  bent  beyond  the  limits  of  its  elasticity  and  the 
strength  of  the  ligaments  which  hold  its  segments 
together.  Parts  of  the  spine,  however,  as  of  the  verte- 
bral arches,  may  be  broken  by  the  direct  violence  of  a 
severe  blow.  Thus,  one  or  more  spinous  processes 
may  be  detached,  and  the  diagnosis  is  made  by  the 
mobility  and  crepitus  which  can  be  easily  elicited. 
When  the  line  of  fracture  is  more  deeply  seated,  and 
runs  through  the  laminae  or  pedicles,  for  instance,  these 
usual  signs  may  be  more  obscure.  Any  such  deep- 
seated  fracture  entails  the  additional  risk  of  bein» 
associated  with  intraspinal  haemorrhage,  and  of  in- 
flammation arising  in  close  proximity  to  the  spinal 
canal.  The  precaution,  therefore,  should  never  be 
neglected,  after  all  severe  blows  on  the  spine  itself, 
of  acting  as  if  fracture  had  unquestionably  occurred, 
and  keeping  both  the  patient  and  the  parts  at  absolute 
rest,  so  that  repair  may  take  place  with  a  minimum 
of  inflammatory  action.  Persistent  pain  in  the  region 
of  one  or  more  vertebrae  increased  by  manipulation, 
and  pain  or  hypersesthesia  in  the  periphery  of  one 
or  more  nerves  emanatincr  from  the  neicjhbourhood  of 
the  injury,  should  excite  the  suspicion  of  fracture. 
Should  paraplegic  or  other  sjTuptoms  of  nerve  disturb- 
ance be  met  with  soon  or  late  as  the  result  of  a 
severe  blow  on  the  spme,  the  symptoms  are  probably 
due  to  intraspinal  haemorrhage  or  to  the  pressure  of 
intlammatory  lymph.  It  is  not  common  for  tlie  spinal 
cord  itself  to  be  aflected  in  such  accidents,  although  it 
has  sometimes  been  found  contused  when  the  blow 


458  Manual  of  Surgery. 

has  been  caused  by  a  bullet  or  shell  striking  the 
spine  with  the  momentum  of  a  great  velocity. 

Fracture-dislocation.— In  fractures  and  dis- 
locations from  indirect  violence  the  cord  is  almost  in- 
variably injured,  crushed  by  the  displaced  vertebra, 
or  torn  by  tlie  sudden  and  excessive  stretching  or 
bend.  Amongst  this  class  of  injuries,  the  commonest 
by  far  are  those  in  which  fracture  and  dislocation  are 
combined ;  but  the  exact  nature  of  the  lesion  depends 
more  upon  the  region  in  which  it  occurs  than  upon 
the  mode  of  accident. 

The  smallness  of  the  cervical  vertebrae,  their 
horizontal  position,  and  the  extreme  flexibility  of  this 
region,  render  uncomplicated  dislocation  most  frequent 
in  the  neck,  although  examples  of  it  have  been  met 
with  lower  down. 

Below  the  neck,  however,  the  "  broken  back  "  is 
usually  a  "  fracture-dislocation,"  from  the  fact  that 
a  greater  violence  is  necessary  to  cause  the  injury, 
and  that  the  vertebrae  are  not  so  readily  separated 
from  each  other.  Thus,  of  394  cases  collected  by 
Ashhurst,  124  were  pure  dislocations,  and  of  these 
104  occurred  in  the  cervical,  17  in  the  dorsal,  and 
3  in  the  lumbar  region.  These  facts  have  an  im- 
portant bearing  on  prognosis  and  treatment,  for  in 
cases  of  pure  dislocation  the  cord  is  somewhat  less 
likely  to  be  irreparably  crashed,  or,  at  any  rate,  lace- 
rated, such  injuries  as  it  receives  being,  perhaps,  from 
simple  pressure  alone.  If,  therefore,  we  can  succeed 
in  reducing  the  displacement  in  the  rare  cases  where 
the  displacement  has  not  undergone  spontaneous  re- 
duction,  the  cord  may  be  thereby  liberated,  the  para- 
lysis from  pressure  on  it  may  disappear,  and  the  risk 
of  destructive  inflammation  spreading  in  its  substance 
may  be  lessened.  And  although  the  etf"orts  to  reduce 
a  displacement  lower  than  the  neck,  where  probably 
fracture  and  dislocation  are  combined,  ax'e  not  so  likely 


Fractures  of  the  Spine. 


459 


to  be  successful,  it  may  be  well  to  make  the  effort, 
that  the  cord  may  have  a  better  chance  of  repair, 
should  it  happen  that  it  has  not  been  crushed  to  pnlp 
by  the  displaced  vertebrae. 

Signs.— In  every  region  deformity  is  a  sign  of 
displacement ;  but  in  the  neck,  in  addition  to  in- 
creased mobility,  and  the  existence  of  a  gap  Ijetween 
spinous  processes,  there  may  be  distinct  projection 
in  the  pharynx,  and  the  patient 
may  experience  difficulty  in 
swallowing.  Lea\'ing,  then, 
for  a  time,  the  nature  of  the 
injuries  in  special  regions,  and 
acknowledging  that  there  may 
be  infinite  variety  of  lesion  in 
different  parts,  there  are  cer- 
tain characteristics  more  or 
less  common  to  all  cases  where 
the  "back"  has  been  "bi^oken" 
by  indirect  violence  or  inordi- 
nate bend.  The  intervertebral 
substance  is  more  or  less  torn 
and  separated  from  the  bone, 
and  the  vertebra,  which  is  the 
upper  one  at  the  site  of  disloca- 
tion, rides  forward  on  that  w^hich  is  below  it,  and  carries 
with  it  all  the  parts  above,  never  being  separated  at  the 
same  time  from  both  its  fellows.  Moreover,  one  or  both 
of  the  articular  processes  may  be  dislocated,  and  a  line 
of  fracture  may  or  may  not  lun  through  any  part  of  the 
vei-tebral  arch.  Ligaments  are  more  or  less  injured, 
lacerated,  or  completely  ruptured,  and  in  the  lower 
part  of  the  column,  in  the  lower  dorsal  region,  for 
example,  where  fracture-dislocation  is  most  common,  it 
is  not  unusual  to  find  that,  in  the  extreme  forward 
bendi]ig  of  the  spine,  a  portion  of  the  body  of  the 
vertebra  immediately  below  the  point  of  separation  is 


Fig. 


93. — Fracture-Disloca- 
tion of  tiie  Spiue. 


460  ATanual  of  Surcekv. 

broken  off  obliquely  from  above  downwards  and  for 
wards  (Fig.  93).  The  deformity  thus  induced  may  be 
permanent  and  irreducible  ;  but  in  the  upper  parts  of 
the  spine,  where  the  segments  are  small,  it  is  by  no 
means  uncommon  for  the  dislocated  parts  to  return  to 
their  natural  positions  instantly  after  the  accident. 
Whether  the  dislocation  has  been  momentary  or 
remains  permanent,  the  cord  is  crushed  at  the  moment 
of  the  accident. 

Injury  to  the  cord  is,  then,  the  source  of  chiefest 
danger  in  all  cases  of  broken  back,  for  inflamma- 
tion is  prone  to  spread  from  the  seat  of  lesion, 
and  gradually  \n.\  olve  the  centres  of  respiration,  and 
cause  death  by  asphyxia.  The  higher  the  lesion, 
therefore,  the  sooner  is  death  imminent  from  spreading 
myelitis,  and  if  we  can  liberate  the  cord  by  the  reduc- 
tion of  displacement,  we  may  perhaps  remove  one  cause, 
at  any  rate,  of  continuing  injury  to  it,  and  give  thereby 
some  better  chance  of  life.  Of  no  case,  however,  is  it 
possible  to  think  hopefully.  We  are  in  the  presence 
of  an  injury  which  is  almost  inevitably  fatal  sooner  or 
later,  and  the  best  we  can  do  is,  by  good  nursing,  to 
make  life  comfortable  and  free  from  suffering  as  long 
as  it  lasts.  The  proposal  made  to  trephine  the  spine, 
so  as  to  relieve  the  cord  from  pressure,  has  met  with 
no  success,  and  has  made  no  footing  in  surgery. 
Trephining  the  sj)ine  has  no  analogy  whatever  to 
trephining  the  skull. 

Syanptoinis»  due  to  injury  of  the  cord. — Pa- 
raplcg'isi.,  or  j^aralysis  of  motion  and  sensation? 
is  commonly  complete,  and  is  of  aJl  parts  below  the 
seat  of  lesion.  It  may,  however,  be  of  lesser  extent, 
and  incomplete,  and  often  motion  is  more  affected 
than  sensation.  The  limit  of  cutaneous  insensibility 
is  usually  well  defined,  and  may  be  mapped  out 
with  accurate  precision,  and  the  boundary  between 
sensibility     and     insensibility     may     sometimes     be 


Fractures  of  the  Spine.  461 

hypersestlietic,  a  phenomenon  probably  due  to  the 
nerve  trunks  being  involved  in  inflammation,  and  so 
irritated  at  the  site  of  lesion.  As  myelitis  spreads  up 
the  cord,  so  the  line  of  insensibility  gradually  rises 
higher. 

When  there  is  no  deformity  the  seat  of  lesion 
has  to  be  determined  by  the  level  of  the  paralysis  ; 
and  then  it  must  be  borne  in  mind  that  the 
nerve  cords  run  with  a  gradually  increasing  obliquity 
downwards  in  the  spinal  canal ;  that  in  the  cervical 
i-egion,  with  the  exception  of  the  eighth,  the  nerves  are 
named  from  the  vertebra  above  wliicli  they  issue,  while 
below  this  region  they  are  named  from  the  vertebra 
below  which  they  come  out  of  the  column.  A  nerve, 
in  fact,  comes  oif  from  the  cord  considerably  higher 
than  its  name  might  imply.  The  cord,  moreover,  is 
most  commonly  injured  at  or  about  the  lowest  part 
of  the  displacement,  that  is,  at  the  part  where  the 
upper  or  dislocated  vertebra  rides  forward  on  the 
vertebra  below  it. 

Speaking  broadly,  the  higher  the  lesion  the  greater 
is  the  immediate  danger,  while  above  the  origin  of  the 
phrenics,  which  issue  above  the  fourth  cervical  ver- 
tebra, death  is  usually  instantaneous  unless  the  cord 
has  not  been  entirely  destroyed. 

When  the  fracture-dislocation  is  below  the  second 
lumbar  vertebra  the  paralysis  may  be  very  irregular  in 
its  distribution,  or  there  may  be  none  at  all,  because 
the  cords  of  the  cauda  equina  are  less  liable  to  in- 
jury than  the  spinal  marrow  itself.  In  any  region 
the  cord  may  be  only  partially  crushed,  and  recovery 
is  then  more  likely  to  ensue,  with  more  or  less  of 
permanent  paralysis. 

In  the  upper  dorsal  region  paralysis  may 
seriously  interfere  with  thoracic  breathing,  which, 
according  to  the  level  of  the  lesion,  will  be  more 
and    more     embarrassed,     until     there     is     nothing 


462  Manual  of  Surgery. 

left  but  diaphragmatic  respiration.  The  diagnosis 
of  this  kind  of  breathing  is  not  difficult.  The 
chest  walls  are  not  motionless,  as  might  have 
been  expected,  but  they  sink  from  atmospheric  pres- 
sure when  the  diaphragm  descends,  and  rise  some- 
what suddenly  again  to  their  previous  position  when 
the  diaphragm  is  once  more  relaxed.  The  chest 
cavity  is  tlierefore  made  small  by  collapse  of  the 
thoracic  walls  just  when  descent  of  the  diai>hragm 
is  compelling  the  entry  of  air  ;  extra  work  is  thus 
thrown  on  the  diaphragm,  and  the  breathing  becomes 
more  and  more  laboured,  for  hypostatic  congestion  of 
the  lungs  soon  arises.  The  alse  nasi  work  vigorously, 
the  patient  is  obliged  to  breathe  through  his  mouth, 
and  his  distress  is  added  to  by  dryness  of  the  throat 
and  tongue. 

Paralysis  of  the  bladder  is  usually  complete 
in  all  cases  of  fracture-dislocation  when  complete 
paraplegia  indicates  the  severity  of  the  cord  lesion. 
Ketention  of  urine  is  commonly  the  first  symptom  of 
it,  and  when  the  bladder  has  become  full  the  urine 
runs  over  and  dribbles  away.  In  the  course  of  a  few 
days,  perhaps,  and  more  especially  after  injury  to  the 
Cauda  equina  alone,  the  bladder  may  regain  a  certain 
amount  of  tone.  The  normal  act  of  micturition  is 
probably  under  the  control  of  special  centres  in  the 
cord,  reaching  from  the  level  of  the  second  to  that 
of  the  fifth  sacral  nerves,  some  centres  being  con- 
nected with  the  sphincter  vesicje,  others  with  the 
detrusor  urinse  ;  and  although  in  paralysis  after  in- 
juries the  action  of  both  these  muscles  is  commonly 
annihilated,  it  is  conceivable  that  one  may  be  affected 
while  the  other  remains  intact.  Thus,  for  example, 
the  bladder  itself  might  be  paralysed  while  the 
sphincter  remained  normal,  and  the  reflex  act  whereby 
the  sphincter  relaxes  in  micturition  being  abolished, 
the  bladder  might  fill  until  it  burst. 


Fractures  of  the  Spine.  463 

It  is  often  impossiLle  to  say  what  is  the  jjre- 
cise  nature  of  the  paralysis,  and  the  state  of 
the  bladder  must  therefore  from  the  first  engage 
the  surgeon's  attention.  A  serious  matter  in 
these  cases  is  the  fact  that  the  nrine  frequently 
becomes  alkaline  and  purulent,  and  presents  all 
those  features  which,  together,  are  characteristic 
of  cystitis.  This  change  in  the  urine  may  appear 
in  the  course  of  a  few  days,  and  is  probably 
due,  in  some  measure,  to  the  outbreak  of  lesions  iu 
some  part  of  the  urinary  tract,  kidney,  ureter,  or 
bladder,  of  the  nature  of  those  "  trophic "  lesions 
which  have  yet  to  be  sjwken  of  under  the  name  of 
bed-sores,  and  to  the  urine  being  contaminated  with 
the  products  of  sloughing  inflammation. 

Cystitis  and  its  symptoms  may  arise  even  when  no 
catheter  has  been  used,  so  that  the  view  which  attri- 
butes it  to  the  introduction  of  septic  matter  into  the 
bladder  is  not  always  tenable.  In  some  cases  it  is  doubt- 
less due  to  the  bladder  being  imperfectly  emptied.  It  is 
a  most  difficult  thing  for  some  persons  to  empty  their 
bladders,  or  even  to  micturate  at  all,  in  the  recumbent 
posture,  and  cystitis  of  a  mild  degree  may  arise 
from  this  cause  even  in  persons  who  have  no  real 
paralysis.  Cystitis  may  become  a  source  of  danger 
by  setting  up  or  aggravating  inflammation  in  the 
urinary  passages,  and  in  chronic  cases  may  cause 
death  by  exhaustion  or  by  the  formation  of  *'  surgical 
kidney."  The  treatment  does  not  differ  from  that 
which  is  suitable  for  cystitis  in  other  cases,  and  no 
catheter  should  be  used  which  is  not  scrupulously 
clean. 

Paralysis  of  the  bowel. — Closely  allied  in  its 
physiological  nature  to  the  act  of  micturition  is  that 
of  defsecation,  which  also  may  be  variously  affected 
after  fracture-dislocations.  The  immediate  effects  de- 
pend, to  a  large  extent,  on  the  contents  of  the  rcctn:n 


464  Manual  of  Surgery, 

at  the  time  of  the  accident.  If  full,  involuntary 
evacuation  will  soon  take  place ;  while  if  empty, 
defsecation  may  not  be  until  tlie  rectum  has  become 
full.  Hence  the  involuntary  act  of  defsecation  takes 
place  only  every  now  and  then.  Constipation  is  very 
common.  Continuous  "  incontinence "  is,  mdeed, 
very  rare  unless  the  motions  are  extremely  loose. 
Occasional  involuntary  evacuation  is  the  usual  rule ; 
but  sometimes  the  patient  acquires  the  power  of  tell- 
ing when  his  rectum  is  becoming  loaded,  and  the 
baneful  consequences  of  involuntary  and  unexpected 
discharge  may  be  thus  avoided. 

When  the  cord  lesion  is  high  up,  additional  dis- 
tress may  be  caused  by  tympanitis,  collection  of 
flatus  being  favoured  by  arrest  or  diminution  of  the 
natural  peristalsis  of  the  intestines.  This,  also,  not 
only  adds  to  the  constipation,  but  may  even  inter- 
fere with  the  already  embarrassed  respiration,  and 
call  for  relief  by  the  use  of  enemata  containing  some 
antispasmodic,  such  as  asafcetida  or  turpentine. 
The  tympanitis  may  also  be  relieved  by  the  passage 
of  a  long  tube  into  the  sigmoid  flexure.  Aspiration 
of  the  gut  in  such  cases  is  not  devoid  of  risk. 

Priapism,  from  vascular  turgescence  of  the  penis, 
is  a  common  result  of  injuries  of  the  cord,  and  is  due, 
in  all  probability,  either  to  passive  distension  of 
vessels  from  vaso-motor  palsy,  or  to  irritation  of 
special  centres,  the  exact  seat  of  which  has  not  been 
determined.  The  state  of  semi-erection  is  most 
marked  during  clie  few  days  which  follow  the 
accident,  while  at  a  later  period  it  may  only  be 
induced  by  some  local  irritation,  such  as  passing  a 
catheter.  Most  commonly  met  with  after  cervical  and 
dor.sal  injuries,  it  has  in  rare  instances  been  seen  after 
fracture-dislocation  still  lower  down.  Its  im|)ort  is 
uncertain,  and  it  is  neither  influenced  by  nor  demands 
treatment 


Bed-sores  in  Spinal  Injuries.  465 

Disturbances  of  temperature  are  sometimes 
very  striking  in  cases  of  fracture  -  dislocation, 
especially  when  the  cord  injury  is  in  the  cervical 
region.  When  the  fall  incidental  to  collapse 
has  passed  away,  there  follows  in  some  instances 
a  very  high  range,  the  thermometer  rising  to 
107°,  108°,  or  even  110°  Fahr.  The  cause  of 
this  hyperpyrexia  is  by  no  means  clear,  but  from 
recent  physiological  observations,  which  have  been 
strikingly  confirmed  by  the  results  of  cei-tain  injuries 
or  lesions,  it  seems  probable  that  the  heat  production 
which  ordinarily  goes  on  in  the  body  tissues  is  no 
longer  restrained  by  supposed  true  calorific  centres, 
having  their  seat  in  the  cerebral  cortex  of  each 
hemisphere  near  the  fissui^e  of  Rolando,  and  having 
crossed  action.  A  lesion  may  cut  ofi"  this  inhibitory 
action  of  one  or  both  centres ;  and  it  is  obvious  that 
this  result  is  most  likely  to  ensue  when  the  injury  is 
high  up,  as  in  the  cervical  region  when  the  cord  is 
wholly  crushed,  and  when  a  larger  area  of  the 
thermo  -  genetic  tissues  is  thus  severed  from  the 
inhibitory  centres  in  the  brain  (Hale  White) 
Sometimes,  also,  in  cases  of  cervical  injury,  the  pulse 
becomes  extremely  slow,  deliberate,  and  full.  The 
precise  seat  of  the  lesions  causing  these  phenomena 
has  yet  to  be  determined. 

Of  far  greater  importance  is  the  occurrence 
of  bed-sores,  to  the  prevention  of  which  the 
surgeon  must  devote  his  earliest  care.  In  all 
probability  there  are  two  kinds  of  bed  -  sores. 
Some  appear  at  points  of  pressure  alone,  such  as  tlie 
sacrum  and  great  trochanters,  and  originate  only  after 
pressure  has  been  long  continued  or  unrelieved.  They 
do  not  difier  from  pressure  sores  in  other  cases,  but 
it  is  more  difiicult  to  prevent  them,  because  the 
paralysed  and  hel})less  }>atient  cannot  gain  relief  l)y 
voluntary  change  of  postux'e.  The  tendency  to  their 
E  E— 21 


466  Manual  of  Surgery. 

formation  may,  however,  be  largely  diminished  by 
placing  the  patient  at  the  earliest  moment  on  a  water 
or  spring  bed ;  and  by  the  use  of  ring  cushions,  stuffed 
with  horse-hair  or  cotton  wool,  we  may  ensure  that 
such  pressure  as  is  unavoidable  may  be  widely  diffused 
instead  of  bearing  on  one  small  point.  The  skin, 
moreover,  may  be  protected  with  plaister,  or  hardened 
by  bathing  it  with  spirit  lotion,  and  all  contact  with 
urine  or  faeces  must  be  prevented.  Bed-sores  of  the 
other  variety  run  a  more  rapid  and  violent  course,  and 
cause  extensive  destruction  of  tissue.  These  also 
are  found  most  commonly  at  sites  of  pressure,  but 
not  invariably  so,  and  they  may  have  a  destructive 
rapidity  which  seems  out  of  all  proportion  to  any 
pressure  which  can  have  been  exerted.  Sometimes 
they  appear  within  a  day  or  two  of  the  accident ;  and 
from  all  their  characteristics  it  seems  highly  probable 
til  at  they  are  really  the  result,  directly  or  indirectly, 
of  some  "  trophic  "  disturbance,  either  due  to  inflam- 
mation of  the  cord,  or  through  the  intermediate 
influence  of  a  peripheral  neuritis  which  has  arisen  as 
the  result,  in  some  as  yet  unexplained  manner,  of  the 
myelitis.  To  such  bed-sores  the  name  "  decubitus 
acutus^'  and  ^^  decubitus  ominosus"  has  been  given, 
and  more  recently  that  of  "  neurojiathic  eschars^ 
While  ever  of  gravest  import,  it  sometimes  happens 
that  the  destructive  process  is  arrested,  the  sloughs 
become  detached,  and  healing  may  ensue.  In  both 
kinds  of  sores  the  detachment  of  slough  may  be 
hastened  by  linseed  or  charcoal  poultices,  and  when 
granulations  have  been  formed  the  ulcer  may  be  dressed 
with  stimulant  ointment  or  lotion,  pressure  being  as 
much  as  })Ossible  avoided. 

Altci'ation  in  tlie  reflexes  is  a  common  se- 
quence of  fracture-dislocation,  and  the  phenomena 
vary  according  to  the  site  of  the  cord  lesion.  When 
situated  in   the  dorso-lumbar   region,  the  knee  jerk, 


Fractures  of  Cervical  Spine.  467 

for  exarn))le,  may  be  abolished  and  may  remain  so ; 
but  it  often  happens  in  the  course  of  a  few  days,  as 
myelitis  sets  in,  that  the  reflexes  become  exaggerated, 
and  a  sensory  stimulus,  such  as  tickling  the  feet,  or 
the  movement  of  the  bed  clothes,  may,  unknown  to 
the  patient,  cause  spasmodic  movements  of  the  legs, 
which  are  most  distressing  and  interfere  with  perfect 
rest.  The  character  of  the  reflexes,  both  superficial 
and  deep,  may  give,  in  both  recent  and  chronic  cases, 
most  valuable  information  as  to  the  site  and  extent  of 
the  cord  lesion.  The  reader  must  refer  to  special 
works  on  nerve  diseases  for  fuller  knowledge  on  this 
subject.  The  injuries  of  special  regions  now  demand 
our  consideration. 

Fracture-dislocation  in  tlie  cervical  re- 
gion.— Separations  between  occiput  and  atlas  are 
most  uncommon,  for  the  range  of  movement  between 
them  is  limited,  and  the  ligaments  are  strong. 
The  most  frequent  injury  in  this  part,  from 
falls  upon  the  head  whereby  the  upper  spine  is 
violently  bent,  is  separation  of  the  atlas  and  axis,  the 
flrst  vertebra  riding  forwards  on  the  second,  and 
causing  instant  death  from  crush  of  the  cord  against 
the  odontoid  process  (Fig.  94).  The  odontoid 
is  itself  sometimes  broken  05",  and  one  or  both 
of  the  check  or  other  ligaments  give  way ;  but 
notwithstanding  that  death  is  usually  instantaneous, 
there  have  been  cases  where  the  odontoid  has  be- 
come anchylosed  in  a  new  position,  and  recovery  has 
taken  place  with  permanent  narrowing  of  the  spinal 
canal. 

Separations  between  the  second  and  third  vertebrae 
are  usually  associated  with  fracture. 

Below  the  third  cervical  we  enter  the  region 
where  pure  dislocations  are  more  common  from  falls 
upon  the  head  and  neck. 

Symptoms.  —  The    cord    is     usually    crushed    iu 


468 


Manual  of  Surgery. 


its  entire  thickness,  and  life  is  rarely  prolonged 
for  more  than  two  or  three  days,  thoracic 
respiration  Ijeing  annulled,  and  diaphragmatic  alone 
left.  The  phrenics  come  out  above  the  fourth 
vertebra,  and  may  escape  injury  even  when  the 
separation  is  at  this  level ;  but  myelitis  will  speedily 
put  an  end  to  the  integrity  of  their  centres.  Below 
this  point,  as  far  as  the  second  dorsal,  it  is  necessary 
to  remember  the  origin  of  the  cords  of  the  brachial 

plexus,  and  the  distribution 
of  its  branches,  in  making  a 
diagnosis  as  to  the  exact  seat 
of  lesion,  and  that  the  de- 
scending branches  of  the 
cervical  plexus  may  allow  of 
perfect  cutaneous  sensibility 
in  parts  much  below  the 
level  of  the  destruction  of 
the  cord.  In  partial  lesions, 
when  the  anterior  cornua  are 
alone  involved,  movements 
may  be  paralysed  according 
to  physiological  rather  than 
anatomical  connections. 
Extension,  for  example,  may  be  paralysed,  while 
flexion  remains  intact,  because  the  correlated  muscles, 
which  cause  a  particular  action  of  a  limb,  are  grouped 
together  in  the  spinal  ganglionic  cells. 

Injuries  to  the  cord  in  the  lower  cervical  and  upper 
dorsal  region  may  cause  jKtrahjtic  myosis,  in  which  the 
pupils  are  unable  to  dilate  l)ecause  of  palsy  of  the 
dilator  fibres  of  the  iris  supplied  by  the  sympathetic, 
which  has  an  intimate  connection  with  this,  the 
"  oculo-pupillary  "  region  of  the  cord.  The  myosis  is 
most  marked  when  unilateral,  but  in  any  case  it  is 
necessary  to  examine  the  eyes  both  in  liglit  and  shade 
in  order  to  recoiJrnise  it. 


Fij?.  94. — Fracture-Dislocation 
of  the  Upper  Cervical  Spine. 


Fractures  of  Dorsal  Spine.  4^9 

Fracfiii'e-clislocutioii  in  the  dorsal  and 
lumbal*  reg^ious. — From  tlie  second  dorsal  vertebra 
do^vn wards,  fracture-dislocations  are  far  more  common 
than  dislocations  alone,  and,  as  a  rule,  the  cord  is  irre- 
parably damaged.  In  fractures  below  the  eleventh  dor- 
sal the  prognosis  is  more  favouralile,  for  the  size  and 
strength  of  the  vertebrae  in  this  region  render  complete 
dislocation  more  difficult,  and  the  cord  escapes  total 
destruction. 

Below  the  second  lumbar  the  cords  of  the  cauda 
equina  are  less  liable  to  injury  than  the  spinal  cord 
itself. 

Paralysis  may  from  the  first  be  incomplete, 
and  there  may  be  considerable  return  of  motion 
and  sensation,  and  of  control  over  bowel  and 
bladder.  Cystitis  and  bed-sores  are  the  chief  risks  to 
which  the  patient  is  exposed.  Deformity  is  likely  to 
be  permanent,  and  when  repair  is  taking  place  the 
application  of  a  Sayre's  jacket  may  give  comfort  by 
ensuring  rest  and  fixation  of  the  spine. 

Injury  to  the  sacro-coccyg:eal  joint. — The 
sacro-coccygeal  joint  may  become  the  seat  of  disease 
from  injury,  and  any  movement  of  it,  as  in  def aecation,  or 
in  excessive  action  of  the  gluteus  maximus,  which  has 
attachment  to  the  coccyx,  may  give  rise  to  pain. 
There  may  also  be  local  heat  and  swelling.  These 
symptoms  and  signs  are  of  impoi-tance  in  diagnosis, 
because  "  coccygodynia,"  or  neuralgic  pain,  is  a  not 
uncommon  affection,  especially  amongst  neurotic 
women.  Rest  is  essential  in  the  one  case ;  it  probably 
has  little  influence  in  the  other,  and  attention  should 
be  rather  directed  to  the  pelvic  \dscera,  uterus,  and 
ovaries. 

Unilateral  dislocations  of  the  spine 
are  not  uncommon  in  the  neck,  from  violent 
bend  or  even  extreme  rotation.  Here  two  articu- 
lar  processes   are   separated   from    each    other,    and 


470  Manual  of  Surgery. 

the  inferior  comes  to  ride  in  front  of  the  superior, 
the  head  is  turned  and  fixed  towards  the 
opposite  side,  local  deformity  may  be  felt  if  the  neck 
is  thin,  and  either  by  some  impairment  of  motion  and 
sensation,  or  by  pain  and  tingling  in  the  periphery, 
there  may  be  evidence  that  the  nerve  which  issues 
from  the  spine  at  the  site  of  injury  is  being  irritated 
by  stretching  or  pressure.  Reduction  should  be 
effected  at  once  by  extension  of  the  neck  so  as  to 
disengage  the  processes,  and  turning  the  head  into  its 
right  position.  Rest  must  be  enforced  for  some  time 
afterwards,  and  the  prognosis  is  favourable  unless 
there  be  fracture  also,  or  the  cord  has  been  itself 
damaged. 

Concussion  of  the  Spinal  Cord. 

This  term  ou^ht  to  be  restricted  to  those  cases 
in  which  an  injury  has  been  inflicted  on  the  cord  from 
blows  upon  the  spine,  similar  and  analogous  to  the  effects 
produced  on  the  brain  by  blows  on  the  skull.  In  the 
case  of  the  head  it  is  well  recognised  that  severe 
concussion  blows  upon  it  may  cause  contusion  of  the 
brain  substance  both  near  the  site  of  the  blow  and  at 
opposite  parts  from  contre-coiqy,  and  in  addition  certain 
effects  which  are  commonly  those  of  collaj)se  from  the 
shock  or  concussion  of  the  whole  brain  mass. 
Although  brain  and  spinal  cord  are  merely  different 
parts  of  one  system,  their  physical  suiToundings  are 
yet  so  different  that  that  which  is  a  common  injury  in 
the  case  of  tlie  brain  is  extremely  rare  in  the  case  of 
the  spinal  cord.  There  are,  indeed,  very  few  cases  on 
recoixl  in  which  it  is  possible  to  say  that  the  cord  has 
been  locally  injured,  stunned,  or  contused  by  con- 
cussion only ;  and  careful  examination  of  many  which 
have  been  so  recorded  sliows  that  sufficient  attention 
has  not  been  paid  to  the  effects  of  direct  contusion 
from  displaced  vertebrae,    of  hiemorrhage  around  the 


Concussion  of  Spine.  471 

cord,  or  of  hsemorrliafje  into  and  laceration  of  its  sub- 
stance  from  violent  sudden  Lend. 

Given,  however,  a  case  in  whicli  the  cord  lias 
been  locally  concussed  or  contused,  the  resultant 
symptoms  are  the  same  as  are  met  with  from 
local  injury  due  to  other  causes ;  and  they 
would  doubtless  be  the  same  if  the  injury  mei-ely 
consisted  in  local  stunning,  for  a  time,  that  is,  until 
the  effects  of  the  concussion  or  stunning  had  j)assed 
away.  Nevertheless,  it  is  extremely  doubtful  whether 
this  latter  condition  ever  follows  local  injury. 

Railway  sjnne. — It  has  been  thought  by  some 
that  the  severe  nervous  disturbances  which  are  seen 
after  railway  collisions  are  due  to  concussion  of  the 
spinal  cord,  but  there  is  no  evidence  that  the 
spinal  cord  is  any  more  affected  than  are  other  organs 
of  the  body  by  the  severe  shock  of  such  accidents  ; 
and  although  it  is  conceivable  that  prolonged  func- 
tional disturbance  thus  originated  may  end  in  struc- 
tural degeneration,  such  a  result  is  very  very  rare,  and 
occurs  perhaps  in  those  only  who,  by  various  causes, 
are  predisposed  to  the  outbreak  of  nerve  disease.  It 
must  not  be  forgotten  that  concussion  of  the  brain  is 
often  caused  in  railway  accidents,  and  many  of  the 
after- symptoms  of  neurasthenia  are  rather  due  thereto 
than  to  injury  to  other  parts  of  the  nervous  system. 
It  has  indeed  been  suggested  that  the  term  "  railway 
brain"  is  more  appropriate  than  "railway  spme." 

Concussion  injuries  of  the  cord,  much  more  analo- 
gous to  concussion  iujuries  of  the  brain,  are  some- 
times met  with  in  connection  with  gun-shot  wound, 
where  the  great  momentum  of  a  bullet  upon  the  spine 
may  cause  contusion  of  the  cord  without  opening  the 
sj)inal  canal.  The  term  also  is  applicable  to  cases 
where  many  minute  lesions,  giving  rise  to  immediate 
paralytic  symptoms,  have  been  caused  by  a  fall  from 
a  height  flat  upon  the  back. 


47? 


XL     INJURIES   AND    DISEASES   OF 
THE    NECK. 

Victor  Horsley. 

L  Wounds  and  Contusions  of  the  Neck. 

A.  Contusions. — A  Llow  directly  on  the  neck 
will  in  all  cases  cause  a  certain  amount  of  ecchymosis, 
i.e.  extravasation  of  blood.  So  long  as  this  is 
superficial  to  the  deep  fascia  it  is  of  no  importance, 
pro\T.ded  the  skin  is  unbroken.  It  frequently  extends 
in  the  loose  subcutaneous  tissue  almost  to  the  middle 
line  posteriorly,  and  in  front  may  reach  below  the 
clavicles  on  to  the  chest.  If,  on  the  other  hand,  the 
extravasation  is  beneath  the  deep  fascia  in  the  loose 
connective  tissue  surrounding  the  large  vessels  and 
nerves,  then  it  will,  by  pressing  on  the  same,  cause 
symptoms  sometimes  of  an  alarming  character. 

As  for  direct  injury  to  the  deep  cervical  structures 
from  a  blow,  we  may  note  an  accident  which  is 
not  an  organic  lesion,  but  a  disturbance  of  function 
which  may  end  fatally,  namely,  spasm  of  the  glottis. 

As  a  result  of  contusion  the  larynx  may  be  frac- 
tured or  the  oesophagus  ruptured.  The  arteries  may 
be  damaged  so  as  to  produce  a  traumatic  aneurism, 
and  injury  of  a  vein  may  lead  to  the  formation  of  a 
blood  cyst.  Injury  of  the  sympathetic  nerve,  if  suffi- 
cient only  to  irritate  it,  will  cause  dilatation  of  the 
pupil  and  protrusion  of  the  eye-ball,  while  if  it  is 
paralysed  then  the  pupil  will  be  dilated,  the  eye-ball 
retracted,  and  the  secretion  of  sweat  on  that  side  of 
the  head  and  neck  interfered  with. 

B.  IrVounds. — Simple  uncomplicated  wounds  of 
the  neck  must  be  treated  on  general  principles,  and 


Wounds  of  Neck.  473 

may  be  expected  to  heal  by  the  first  intention  if  tlie 
parts  are  kept  perfectly  at  rest.  For  this  purpose  the 
patient's  head  and  neck  should  be  fixed  by  being 
placed  between  sand-bags  covered  with  a  thin  pillow, 
or  a  light  splint  of  guttapercha  may  be  fitted  to  the 
shoulders  and  nape  of  the  neck,  so  that  the  head 
cannot  turn.  After  ligature  of  large  vessels  this  pre- 
caution should  always  be  taken. 

^Vouiids  of  special  parts. — Punctured  wounds, 
stabs,  etc.,  in  the  2?osterior  triangle  may  reach  the 
subclavian  vessels,  the  brachial  and  cervical  plexuses, 
the  spine  and  spinal  cord. 

If  the  large  vessels  are  wounded,  and  the  haemor- 
rhage temporarily  arrested  by  plugging,  pressure  is 
to  be  made  on  the  proximal  side  of  the  wound,  which 
must  then  be  laid  freely  open  and  the  vessel  tied  with 
chromic  catgut,  and  the  wound  dressed  antiseptically. 
If  one  of  the  cervical  nerves  entering  the  brachial 
plexus,  or  one  of  the  cords  of  the  plexus,  is  divided 
by  a  cut,  and  no  restoration  of  motor  power  has  been 
attained  at  the  end  of  five  or  six  weeks,  the  wound 
must  be  reopened  and  the  nerve  sutured.  If  the 
spinal  cord  is  reached  by  a  knife,  bayonet,  etc.,  then 
the  special  symptoms  of  paralysis,  etc.,  will  denote 
the  amount  of  injury  (Art.  x.),  and  treatment  must 
be  mainly  directed  to  providing  very  free  drainage 
of  the  wound,  coupled  with  the  liberal  use  of  anti- 
septics. Wounds  in  the  front  of  the  neck  and  of  the 
anterior  triangle  may  be  here  considered  together, 
although  in  some  points,  especially  in  their  after 
effects,  the  regions  differ.  (>S'ee  Cellulitis  of  the  neck, 
page  477.) 

"Wounds  of  the  front  of  the  neck  and  of  the  an- 
terior triangle  may  injure  (1)  the  air  passage  ;  (2)  the 
food  passage ;  (3)  the  large  vessels ;  (4)  the  large  nerves. 
The  ordinaiy  cut  throat  of  the  suicide  or  homicide  has 
always  received  special  notice  in  surgical  text-books, 


474  Manual  of  Surgery. 

but  presents  nothing  peculiar  in  itself,  unless  it  be 
endless  variations  in  the  extent  of  the  lesion.  Conse- 
quently, the  symptoms  attendant  on  injury  of  various 
important  structures  noted  above  will  be  described  in 
detail,  vA\h  their  appropriate  treatment,  and  as  such 
symptoms  are  very  distinct,  any  corajilicated  case  of 
cut  throat  is  merely  a  combination  of  some  of  the 
above  possible  accidents.  However,  it  cannot  be  too 
often  insisted  upon  as  a  general  fact,  applicable  to  all 
cases,  that  the  main  importance  of  a  wound  in  the 
neck  does  not  lie  in  the  immediate  symptoms  it 
presents,  however  urgent,  but  in  the  possibility  of 
complications  arising  in  the  after-treatment ;  for  since 
the  former  can  be  met  by  the  ordinary  rules  of  action 
in  surgical  emergency,  the  sequelse  (cellulitis,  pneu- 
monia, etc.)  really  determine  the  result  of  the  case, 
and  therefore  the  prognosis  too. 

1.  Wounds  of  the  air  jmssage.  —  The  pharynx 
may  be  opened  by  a  horizontal  cut  passing  above 
the  hyoid  bone  through  the  base  of  the  tongue,  or 
below  the  hyoid  bone  in  the  thyro-hyoid  space. 
Here,  if  the  pharynx  be  extensively  opened,  the  cut 
divides  the  epiglottis  more  or  less  completely  according 
to  the  position  it  was  in  at  the  time.  The  divided 
epiglottis  has  sometimes  caused  asphyxia  by  dropping 
into  the  glottis,  plugging  it  up,  and  exciting  spasm. 
In  either  of  these  kinds  of  severe  cut-throat  about  the 
hyoid  bone,  air  and  food  will  escape  through  the 
wound,  and  the  tongue,  when  thus  cut  free  from  the 
hyoid  bone,  frequently  presses  backwards,  and  i)ro- 
duces  more  or  less  sufibcation  ;  it  must  in  such  a  ca.se 
be  drawn  forward  by  a  silk  loo))  passed  through  it. 
After  thorough  washing  out  of  the  part  with  carbolic 
solution,  the  wound  in  the  mucous  membrane  of  the 
pharynx,  where  feasible,  may  b(3  closed  by  sutures 
placed  entirely  in  the  submucous  tissue,  the  angles  of 
the  skin  wound  apposed  by  a  few  horsehair  sutures,  and 


Wounds  of  Neck.  475 

free  dvaiiiage  with  a  large  tube  arranged  in  the 
middle  third  of  the  space.  The  wound  heals  always 
by  granulation,  as  the  movement  of  the  parts  prevents 
adequate  rest  for  primary  union,  and  it  usually  heals 
quickly  if  kept  very  clean  by  frequent  iiTigation.  It 
must  be  wiped  out,  not  syringed,  if  the  glottis  is 
exposed. 

The  larynx  is  usually  opened  by  one  or  several 
transverse  cuts  about  the  lower  part  of  the  thyroid  carti- 
lage. While  no  special  symptoms,  beyond  the  usual 
escape  of  air,  etc.,  directly  accompanies  this  condition,  it 
is  esjiecially  liable  to  be  followed  by  the  very  dangerous 
sequel  of  acute  inflammatory  cedema  of  the  glottis. 
The  glottis  being  cut  into,  usually  above  the  vocal 
cords,  it  is  exposed  to  the  air,  to  irritation  by  blood, 
etc.,  and  so  acute  cedema  (in  which  the  mucous  mem- 
brane becomes  extremely  swollen  by  exudation  in- 
to the  loose  submucous  tissue)  being  excited,  the 
lumen  of  the  larynx  is  choked,  and  the  patient 
rapidly  becomes  asphyxiated  unless  a  tube  is  passed 
into  the  trachea.  For  this  reason  it  is  advisable 
to  perform  tracheotomy  whenever  the  glottis  is  the 
seat  of  the  wound,  for  the  rapidity  with  which 
cedema  glottidis  sets  in  is  so  extreme  as  to  sometimes 
kill  the  patient  before  the  operation  can  be  performed. 
At  the  moment  when  the  wound  is  inflicted  there  is 
danger  of  asphyxia  from  blood  running  down  between 
the  vocal  cords  and  tilling  the  air  passages  ;  and  a  rela- 
tively small  quantity  of  blood  can  thus  produce  fatal 
asphyxia,  unless,  of  course,  the  patient  is  able  to 
cough  it  up.  In  addition  to  oedema  glottidis,  the 
complication  of  emphysema  may  arise,  in  which 
condition  the  subcutaneous  tissues  of  the  neck  become 
infiltrated  with  air  and  enormously  swollen. 

Finally,  when  the  vocal  cords  are  injured,  or  the 
cricoid  cartilage  is  cut  through,  the  voice  is  eitlier  com- 
pleLuly  abolished  or  very  much  weakened  and  hoai'sc. 


476  Manual  op  Surgery. 

If  the  trachea  is  only  opened  for  a  small 
distance,  it  will  heal  readily,  as  most  tracheotomy 
wounds  do.  If,  however,  as  rarely  happens,  it  is  very 
severely  wounded  (it  has  been  seen  completely  cut 
across),  it  should  be  united  with  fine  catgut  sutures, 
the  wound  being  kept  freely  open  and  frequently 
cleansed. 

2.  Wounds  of  the  food  passage  are  described  in 
Art.  v.,  vol.  iii.  Note  may  here  be  taken  of  the 
risk  of  septic  infection  with  this  complication-  Where 
possible  the  mucous  membrane  of  the  alimentary  canal 
should  be  closed  by  sutures. 

3.  There  is  no  mystery  about  the  symptoms  of 
wound  of  one  of  the  large  vessels.  If  seen  in  time 
the  bleeding  point  should  be  caught  between  the 
thumb  and  fore-finger  of  the  left  hand,  one  digit 
(preferably  the  thumb)  being  thrust  to  the  bottom  of 
the  wound,  the  other  being  outside,  pressing  on  the 
stemo-mastoid  muscle.  The  bleeding  being  thus 
absolutely  arrested  for  the  moment,  the  wound  should 
be  enlarged  up  and  down  for  a  short  distance,  the 
fresh  incision  dividing  the  deep  fascia.  A  finger  of 
the  right  hand  can  now  be  brought  to  exert  fii-m 
pressure  directly  on  the  trunk  of  the  bleeding  vessel, 
the  wound  in  which  can  then  be  exposed  by  removing 
the  left  hand.  It  can  then  be  completely  closed  by 
catch  forceps.  If  the  original  wound  gape  very 
widely  there  will  be  no  necessity  to  enlarge  it,  but  no 
time  is  to  be  wasted  in  trying  to  compress  the  vessels 
through  the  intact  structures  of  the  neck.  The 
wound  in  the  vessel,  now  under  perfect  control,  is  to 
be  permanently  closed  by  ligature  of  the  trunk  above 
and  below  it.  The  wound  is  then  to  be  disinfected 
and  dressed. 

4.  Injury  of  the  large  nerves  has  already  been 
alluded  to. 

In  concluding  the  subject  of  wounds  of  the  neck, 


Cellulitis  of  Neck.  477 

attention  is  again  drawn  to  the  fact  that  the  majority 
of  oases  end  fatally  because,  the  wound  decomposing, 
the  foul  discharge  either  sets  up  cellulitis,  which 
spreads  down  into  the  mediastinum,  or  it  enters  the 
trachea  and  sets  up  septic  pneumonia.  Every  care, 
therefore,  is  to  be  exerted  towards  thorough  cleansing 
and  disinfection  of  the  wound. 

II.     Cellulitis  of  the  Neck. 

To  grasp  fully  the  conditions  under  which  the  loose 
connective  tissues  of  the  neck  become  the  seat  of  cellu- 
litis the  arrangement  of  the  cervical  fasciae  must  be 
borne  in  mind.  CeSluIitis  may  be  started  in  any 
one  of  the  regions  of  the  neck  occupied  by  connective 
tissue,  by  several  causes,  the  commonest  of  which  is 
inflammation  of  a  gland,  almost  invariably  a  lymph 
gland,  and  more  rarely  the  salivary  glands.  The 
lymph  glands  are  liable,  of  course,  to  become  inflamed 
by  absorption  of  septic  matter  from  a  sore  inside  the 
mouth  and  pharynx,  or  elsewhere,  especially  in  some 
acute  specific  fevers,  e.g.  scarlet  fever,  diphtheria, 
when  the  swellinor  of  the  neck  receives  the  title  of 

O 

scarlatinal  angina,  cynanche  maligna,  etc.,  the  name 
simply  signifying  that  the  connective  tissue  around 
the  glands  is  in  a  state  of  acute  phlegmonous  inflam- 
mation. 

Next  to  acute  inflammation  of  the  glands  as  a 
cause  of  cervical  cellulitis,  comes  chronic  adenitis, 
which  is  usually  of  tubercular  origin,  then  wounds 
and  injuries  of  the  soft  ])arts  of  the  neck,  alveolar 
abscess  from  carious  teeth,  and,  Anally,  specific  poisons, 
which  produce  the  particular  form  of  cer\ical cellulitis 
known  as  angina  Ludovici  (or  Ludovigii),  and  the 
rare  parasitic  disease  known  as  actinomycosis. 

Cervical  cellulitis  presents  itself  in  various  degrcoa 
of  severity,  as  cellulitis  does  everywhere.  Thus  wo 
may  have  a  simple  but  acutely  developed  oedema  (acute 


4  7^  Manual  of  Surgery. 

inflammation)  of  the  connective  tissue  spaces  as  occurs 
sometimes  in  diphtheria.  Or  this  may  be  phleg- 
monous, as  in  many  cases  of  septic  poisoning  and 
scarlet  fever,  the  centre  of  the  phlegmonous  mass 
softening  down  into  an  acute  abscess.  Further  than 
this,  the  inQammation  may  be  of  so  virulent  a  type 
that  the  result  is  gangrenous  destruction  of  the 
tissues,  producing  sloughs  bathed  in  a  horribly  foetid 
ichorous  fluid. 

As  the  best  example  of  this  latter  condition  may 
be  detailed  the  aflfection  known  as  angina  Ludovic% 
or  submaxillary  cellulitis  or  angina.  The  general 
causes  which  excite  cervical  cellulitis  have  just  been 
mentioned,  but  it  will  easily  be  understood  that  the 
condition  of  submaxillary  cellulitis  is  most  usually 
started  by  a  local  spreading  inflammation  from  an 
abscess  round  a  carious  tooth,  or  from  septic  in- 
flammation of  the  submaxillary  gland. 

Angina  Ludovici  begins  like  an  acute  specific  fever, 
and  when  not  treated  runs  a  very  rapid  course,  ending 
fatally,  sometimes  in  from  five  to  nine  days.  It 
begins  with  pyrexia,  the  temperature  rising  rapidly 
to  103°,  104°,  ushered  in  by  a  rigor,  accompanied  by 
headache,  depression,  and  loss  of  appetite.  When 
these  symptoms  are  well  declared,  there  then  begins 
a  swelling  under  the  jaw,  which  is  simply  due 
to  oedema  of  the  connective  tissue.  The  swelling 
forces  the  tongue  upwards  and  backwards  so  as  to 
form  a  large  unwieldy  mass  in  the  mouth.  This 
causes  some  pain  in  swallowing,  and  interferes  with 
the  free  movement  of  the  jaw  and  with  speech.  Fre- 
quently there  is  comparatively  little  pain  in  this  afiec- 
tion  ;  but  sometimes,  if  the  swelling  is  developed  very 
rapidly,  the  pain  is  severe,  until  the  limiting  fascia 
gives  way  and  allows  the  pus  to  infiltrate  the  surround- 
ing tissues,  when  the  patient  experiences  considerable 
relief.     Tf  the  swelling  is  incised  at  this  time  it  will 


Cellulitis  of  Neck. 


479 


be  found  to  be  composed  of  slougliy,  but  solid,  connec- 
tive tissue,  infiltrated  with  foul  gi-eyish-brown  sero- 
pus.  The  muscles  become  infiltrated  secondarily,  and 
the  cellulitis  may  spread  into  the  anterior  mediastinum 
and  even  reach  the  pericardium,  the  patient  dying  of 
exhaustion  and  septicemia  if  not  relieved. 

Treatment. — In  all  cases  an  incision,  from  1  inch 
to  \\  inches 
long  is  to  be 
made  through 
the  skin  and 
snperficial  fat, 
any  vein  di- 
vided being 
picked  up  with 
catch  forceps. 
If  the  cellulitis 
is  clearly  de- 
fined and  local- 
ised to  one  or 
the  other  spaces 
of  loose  cellular 
tissue  in  the 
neck,  then  it 
clearly  must  be 
under  the  deep 
fascia,  which  is 
therefore  to  be  divided  to  the  same  extent  as  the  skin. 
A  certain  amount  of  serous  oedema  fluid  will  ooze  into 
the  wound  from  the  cut  tissues.  A  steel  director  is  now 
to  be  thrust  carefully  towards  the  centre  of  the  swelling, 
and  if  foul  ichorous  matter  flow  along  the  groove  of 
the  director,  a  pair  of  dressing  forceps  is  to  be  thrust 
(closed)  along  the  groove  to  the  centre  of  the  abscess, 
and  then  withdrawn  with  the  blades  moderately  sepa- 
rated so  as  to  dilate  the  opening.  Finally  a  large 
drainage   tube   should    be   inserted,    and   the    whole 


Fig.  95.— Incisions  for  Cellulitis  of  the  Neck. 


4 So  Manual  of  Surgery. 

syringed  out  with  warm  carbolic  acid  solution.  The 
neck  should  then  be  wrapped  in  hot  fomentations 
of  boracic  lint. 

The  line  of  incision  varies  according  to  the  space 
to  be  opened  (Fig.  95).  Thus,  in  the  posterior  tri- 
angle the  cuts  should  be  made  parallel  to  the  main 
vessels  and  nerves,  taking  care  at  the  fore  part  not  to 
wound  the  external  jugular  vein. 

To  open  the  spaces  in  front  of  the  neck  in  angina 
Ludovici,  the  incision  must  always  be  made  in  the 
middle  line,  and  if  necessary  a  further  one  may  be 
carried  through  the  centre  of  the  swelling,  but  this 
is  rarely  necessary.  The  connective  tissue  space 
around  the  carotid,  etc.,  is  to  be  opened  as  in  the 
operation  for  ligature  of  that  vessel,  namely,  parallel 
to  the  sterno-mastoid. 

III.     Tumours  op  the  Neck. 

Tumours  of  the  neck  include  among  their  varieties 
several  kinds  which  are  peculiar  to  the  region  in- 
volved, these  mostly  being  congenital  in  origin. 
Viewed  as  a  whole  they  may  very  justly  be  divided 
into  two  main  classes,  viz.  cystic  and  solid  tumours. 
Cysts  are  usually  arranged  according  to  their  contents, 
but  for  clinical  purposes  are  best  grouped  in  the 
anatomical  order  of  the  parts  they  arise  from,  and 
the  same  method  will  be  employed  in  treating  of  the 
solid  tumours. 

A.  Cystic  Tumours. 

1.  Cystic  tiiiiioiirs  arising:  from  persis- 
tence of  embryonic  structures. — The  fissures  in 
the  neck,  known  as  visceral  clefts  in  the  embryo, 
sometimes  do  not  close,  or  only  partially,  i.e.  at  both 
ends  and  not  in  the  middle,  or  at  one  end  only.  If 
the  first  imperfection  exists,  there  may  be  found  a 
prolongation  of  the  angle  of  the  mouth  almost  to  the 


Tumours  of  Necic 


481 


ear,  while  at  three  points  between  the  lower  border  of 
the  jaw  and  the  thorax  it  may  present  itself  as  a  sinus- 
like cavity,  running  upwards  and  backwards  from  the 
front  of  the  neck,  sometimes  only  just  admitting  a 
probe,  and  always  secreting  a  little  thin  mucous  fluid. 
If  the  ends  of  such  a  "  congenital  fistula  "  are  closed 
and  the  centre  patent,  then  there  develops  a  congenital 
cystic  tumour,  which  may  reach  a  large  size  and 
extend  deeply  (sometimes 
to  the  spine),  so  as  to  form 
important  connections  with 
the  large  vessels  and  nerves. 
These  cysts  form  rounded, 
painless  swellings,  with  ex- 
ceedingly thin  walls,  and 
the  skin  over  them  non- 
adherent (Fig.  96).  They 
usually  contain  a  serous 
fluid,  and  therefore  come 
under  the  general  appella- 
tion of  ^*  hydrocele  colli,'' 
but  in  some  rare  instances 
they  are  lined  by  one  or 
more  layers  of  epithelial 
cells,   and    contain    a  fatty 

material.  If  it  should  prove  impossible  to  extir- 
pate these  cysts  (after  repeated  aspiration  has  been 
tried),  they  should  be  injected  with  iodine  or  car- 
bolic acid. 

The  other  common  class  of  congenital  cystic 
tumours  are  often  called  dermoid,  but  it  must  not  be 
supposed  that  they  always  contain  examples  of  all 
dermal  appendages.  These  dermcrid  c}'sts  usually  are 
found  in  the  middle  line,  where  the  somatic  plates 
fuse  together,  and  they  arise  no  doul)t  from  small 
masses  of  included  epiblast.  As  may  readily  be  ima- 
gined, they  are  also  found  in  the  sites  of  the  visceral 


Fig.  96.— Large  Congenital  Hy- 
di'ocele  of  tlie  Neck. 


482  Manual  of  Surgery. 

clefts,  but  this  position  is  rarer.  The  commonest 
seat  is  between  the  genio-hyoid  muscles,  where  the 
tumour  presents  itself  as  a  rounded  swelling  in  the 
middle  line,  just  above  the  hyoid  bone.  It  pushes  up 
the  floor  of  the  mouth  and  the  tongue  so  as  to  project 
considerably  beneath  the  buccal  mucous  membrane 
These  cysts,  when  they  occur  on  the  side  of  the  neck, 
often  form  dangerous  adhesions  to  the  large  vessels. 
Like  the  "  hydrocele "  cysts,  these  have  very  thin 
walls,  but  unlike  them,  the  dermoid  contents  always 
contain  a  large  quantity  of  yellowish-white  fcitty 
debris  (cholesterine,  etc.),  ^vith  epithelial  cells.  More 
rarely  hair,  sebaceous  matter,  and  teeth  have  been  found 
in  them.  They  must  be  extirj^ated  with  special 
attention  to  surrounding  structures. 

2.  Cystic  ttuuoui's  arising^  from  the  air 
ami  food  passages. 

(a)  Cysts  containing  air  may  arise  in  the  neck  from 
either  the  apices  of  the  lungs  projecting  up  under 
the  sterno-mastoid,  or  from  the  side  (usually)  of  the 
trachea  {tracheocele).  In  the  first  case  the  cyst  is 
an  example  of  hernia  of  the  lung  (Ai*t.  i.,  vol.  iii). 
In  the  second  case,  as  the  result  of  maldevelop- 
ment,  the  parts  are  not  united  in  the  middle  line, 
so  that  a  tracheal  fistula  is  left ;  or  one  or  more  rings 
are  wanting  so  as  to  render  a  hernia  of  the  mucous 
membrane  of  the  trachea  possible  when  powerful  expi- 
ratory effects  are  made,  especially  if  the  glottis  be 
closed. 

(6)  The  bursa  between  the  hyoid  bone  and  the 
thyroid  cartilage  may  enlarge  and  become  distended 
with  fluid.  It  should,  if  acutely  inflamed,  be  treated 
with  leeches  and  hot  fomentations.  It  may  require 
aspiration,  but  I  have  seen  the  fluid  absorbed  in 
about  a  month  in  the  case  of  a  young  man  who 
refused  all  treatment.  Aspiration  is  always  of 
service. 


Tumours  of  Neck.  483 

(c)  Cystic  tumours  may  originate  in  the  mucous 
glands  of  both  trachea  and  oesophagus  ;  the  secretion 
being  pent  up  so  as  to  form  retention  cysts. 

3.  Cysts   arising  from  the  blood-vessels. 

(a)  The  commonest  blood  cystic  tumour  in  the 
neck  is  an  aneurism  (Art.  xxvii.,vol.  i.). 

(b)  The  next  commonest,  perhaps,  is  a  simple  cyst 
containing  blood;  the  cyst  being  developed  in  con- 
nection with  a  vein  or  in  an  enlarged  venous  plexus. 
Another  variety  of  cyst  containing  blood,  more  or  less 
altered,  however,  is  the  so-called  hsemorrhagic  cyst, 
which  condition  results  from  rupture  of  some  small 
vein  or  veins  leading  to  the  formation  of  a  cystic 
cavity.  Asj^iration  of  this  kind  of  cyst  sometimes 
draws  off  blood  so  altered  as  to  present  a  chocolate- 
like appearance. 

(c)  The  third  kind  of  blood  cystic  tumour  is 
venous  angioma,  which  develops  in  the  neighbourhood 
of  the  vessels,  usually  in  the  posterior  triangle. 
Beyond  being  extremely  rare,  it  does  not  differ  from 
ordinary  venous  angioma. 

The  treatment  of  blood  cysts,  omitting  aneurism, 
depends  on  the  nature  of  the  cyst.  If  the  latter  is  in 
connection  with  a  large  vein  and  is  of  moderate 
size,  it  is  to  be  exposed,  and  the  pedicle  or  the 
feeding  vessel  ligatured.  If  this  is  impossible 
it  must  be  treated  like  an  aneurism,  viz.  by 
electrolysis,  etc.  A  hsemorrhagic  cyst  requires  dis- 
secting out  where  possible  ;  if  not,  it  must  be  scraped 
and  drained.  Venous  angioma  in  the  neck  is  always 
best  treated  by  frequent  puncture  with  the  actual 
cautery  at  a  dull  red  heat. 

4.  Cysts  arising:  from  lymph  vessels. - 
Lymph  cysts  containing  a  thin  serous  fluid  are 
probably  more  common  than  is  generally  believed. 
From  their  watery  contents  and  the  deformity  pro- 
duced they  have  been  named  "hygroma  colli."     They 


484  Manual  of  Surgery. 

are  divisible  into  two  classes,  congenital  and  ac- 
quired. 

Congenital  hygroma  is  a  very  grave  affection,  the 
exact  origin  of  which  is  not  very  clear.  A  child 
is  born  with  a  sero-cystic  tumour  usually  over  the 
carotid,  the  gi'owth  steadily  increasing  and  causing 
death  by  pressm-e  on  the  oesophagus,  trachea,  and 
blood-vessels.  If  punctured,  it  is  found  that  the 
cyst  is  composed  of  loculi  communicating  with  one 
another,  and  the  walls  of  each  firmly  adherent  to  the 
large  vessels  and  nerves.  The  treatment  should 
consist  in  incision  and  antiseptic  drainage. 

In  the  adult  a  lymphatic  cyst  (acquired  hygroma) 
in  the  neck  is  usually  a  single  cavity  formed  by  a 
fairly  thick- walled  sac,  which  is  lined  by  lymphatic 
endothelium,  so  that  there  is  little  doubt  of  the  nature 
of  the  tumour.     It  should  be  excised. 

5.  Simple  sebaceous  (atheromatous)  cysts 
of  the  neck  are  not  uncommon,  and  require  no 
further  notice  here. 

6.  Hydatid  cysts  of  the  neck.— Very  rarely, 
?.e,  in  0*5  per  cent,  of  all  cases  of  hydatid  disease,  has 
the  echinococcus  been  found  in  cysts  of  the  neck. 
Treatment  should  be  by  incision  and  drainage. 

Little  has  been  said  of  the  differential  diagnosis 
between  the  various  cysts  described  above,  because 
the  diacrnosis  between  the  different  kinds  is  rendered 
sufficiently  obvious  by  the  description  of  each  ;  but  it 
is  important  to  point  out  that  they  may  be  confounded 
wdth  soft  solid  tumours,  e.g.  lipoma,  and  with  abscesses 
(especially  if  chronic).  In  most  cases  aspiration  with 
an  exploratory  syringe  is  harmless  if  performed  anti- 
septically,  and  with  due  caution,  while  it  frequently 
definitely  decides  the  diagnosis. 


Tumours  of  Neck.  485 

B.     Solid  Tumours  in  the  Neck. 

The  following  description  of  the  solid  tumours  is 
arranged  according  to  the  tissues  they  begin  in. 

1.  Ttimoiirs  groTring:  from  the  skin  and 
connective  tissues.— The  skin  itself  is  occasionally 
the  seat  of  nsevi,  warts,  and  epithelioma,  the  latter 
occurring  especially  in  old  cicatrices.  These  require 
no  special  notice.  The  subcutaneous  tissue  is  very 
frequently  the  seat  of  one  of  the  simple  growths,  e.g. 
fibroma  and  lipoma,  which  are  most  common  in  the 
posterior  triangle.  More  rarely  enchondroma  and 
osteoma  have  been  found  springing  from  the  remnants 
of  the  visceral  arches  or  so-called  cervical  ribs. 
Primary  sarcoma  has  been  described  growing  in  the 
connective  tissue,  especially  in  the  anterior  triangle. 
Special  difficulties  in  diagnosis  can  only  arise  when 
these  tumours  are  soft  and  growing  deeply  in  fat 
subjects. 

2.  Tumours  of  the  muscles.— These  are 
very  rare.  There  is,  however,  a  definite  tumour 
peculiar  to  the  cervical  muscles,  especially  to  the 
sterno-mastoid,  and  occurring  in  new-born  children- 
which  must  be  noticed  here.  In  breech  presenta, 
tions,  and  in  children  the  subjects  of  congenital 
syphilis,  there  is  often  noticed  after  bii'th  a  steadily 
increasing  swelling  about  the  middle  of  the  sterno-mas- 
toid muscle,  which  at  the  end  of  a  month  may  inter- 
fere with  swallowing,  etc.  It  is  clearly  a  syphilitic 
formation  at  a  point  damaged  by  rupture  at  birth, 
and  is  best  treated  with  mercury  and  external  anti- 
inflammatory remedies. 

3.  Tumours  of  the  lymph  glands.— These 
glands  give  rise  to  by  far  the  largest  number  of 
tumours  in  the  neck,  so  that  it  is  worth  while  to 
digress  for  a  moment  to  recall  to  mind  their  normal 
position.     Besides    the    glandulae    concatenatre    lyino 


4^6  Manual  of  Sitt^cfry. 

along  the  posterior  border  of  the  stemo -mastoid 
muscle,  the  following  are  constant  sites  for  lymphatic 
glands,  viz.  over  the  carotid  just  at  its  bifurcation ; 
a  few  smaller  ones  being  arranged  along  the 
carotid  sheath  upwards  and  downwards  from  this  point ; 
over  the  submaxillary  gland  just  below  the  body  of 
the  jaw;  between  the  genio-hyoid  muscles;  over  the 
parotid  gland  in  front  of  tho  tragus  of  the  pinna, 
and,  occasionally,  beneath  the  parotid.  Lymph  glands 
may  give  rise  to  tumours  under  the  following  con- 
ditions : 

Sim])le  hypertrophy  sometimes  wrongly  described 
as  lymphadenoma.  The  glands  simply  increase  in 
size  and  density,  the  skin  is  freely  movable  over 
them  and  not  reddened;  the  swelling  is  painless, 
as  a  rule,  and  non-adherent  to  surrounding  struc- 
tures. In  true  lymphadenoma  the  cervical  glands 
partake  of  the  general  numerical  enlargement,  some- 
times forming  enormous  collar-like  masses  on  the 
sides  of  the  neck.  In  these  cases  the  glands  are  often 
so  adherent  to  one  another  as  to  form,  practically,  a 
confluent  mass.  Simple  enlargement  occurs  in  young 
individuals  placed  under  bad  hygienic  conditions,  or 
over-worked,  etc.  The  treatment  consists  in  local 
counter-irritation  by  iodine,  interstitial  injection  of  the 
same,  and  general  constitutional  treatment.  And  if 
all  these  means  fail,  excision  of  the  mass  should  be 
performed.     {See  Art.  xxviii.,  vol.  i.) 

Strumous  disease.  —  Chronic  inflammatory  changes, 
in  which  caseation  occurs  early,  is  found  in  the  cervi- 
cal glands  both  in  children  and  adults.  The  condition 
is  described  in  Art.  xix.,  vol.  i.,  to  which  reference  is 
directed. 

Chronic  inflammatory  and  syphilitic  enlargement. 
— ^These  require  only  to  be  mentioned  as  causes 
of  tumour  in  this  region,  reference  for  further  detail 
being  made  to  Art.  xxii.,  vol,  i 


Parotiditis.  487 

Primary  new  growths.  —  The  commonest  new 
grow-th  commencing  in  the  lymph  glands  is  sarcoma, 
it  may  be  spindle-celled  or  round-celled,  usually 
the  latter,  which  is  consequently  termed  lympho- 
sarcoma. Tliis  is  excessively  malignant,  grows  with 
great  rapidity,  and  involves  surrounding  structures. 
Scattered  glands  may  be  attacked  simultaneously. 
Early  excision  is  the  only,  but  not  a  promising, 
treatment. 

Secondary  new  growtJis.  —  Cancer  and  round- 
celled  sarcoma  usually  involve  the  lymph  glands 
secondarily.  Cancer,  especially  epithelioma,  invades 
the  glands  nearest  the  original  tumour.  The  enlarge- 
ment of  the  gland  is  usually  irregular,  painful, 
and  hard.  It  soon  becomes  very  adherent  on  the 
outside  to  surrounding  structures,  while  it  degenerates 
in  the  centre  so  as  to  form  a  cavity  filled  with  pul- 
taceous  debris.     Early  excision  is  the  only  treatment. 

IV.  Affectioxs  of  the  Salivary  Glaxds. 
A.   Simple  infla.iaiuiatiosi  of  the  parotid. — 

The  parotid  gland  inflames  rarely  from  direct  primary 
causes,  but  very  frequently  as  a  symptom  of  some 
acute  specific  disease.  It  is  so  common  a  feature 
of  mumps  as  to  almost  render  the  terms  parotitis 
and  mumps  synonymous.  It  also  occurs  frequently 
in  pyaemia,  and  more  rarely  in  scarlet  fever,  typhus, 
and  small-pox.  Acute  adenitis  of  the  submaxillary 
gland  is  as  rare  as  that  of  the  parotid  is  common. 
Parotitis  usually  presents  itself  as  congestion  and 
oedema  of  the  gland,  the  acute  swelling  being  painful, 
and  causing  movement  of  the  jaw  to  be  very  limited. 
The  incubation  period  of  mumps  is  about  three  weeks, 
and  after  the  swelling  has  developed,  and  is  disap- 
pearing in  one  gland,  the  opposite  one  becomes  affected. 
Suppurative  parotitis  only  occurs  in  very  debili- 
tated subjects,  and  in  pyaemia.     In  the  latter  affectioB 


488  Manual  of  Surgery. 

it  is  lieralded  by  a  severe  rigor,  and  is  Tisually 
found  to  form  a  localised  swelling,  although  the 
phlegmonous  infiltration  around  spreads  through  the 
whole  gland.  Early  antiseptic  incision  is  the  only 
treatment,  coupled  with  the  general  treatment  of 
pyaemia. 

Gangi-enous  parotitis  is  a  very  rare  affection,  in 
which  the  inflammation  terminates  in  sloughing  of  the 
superjacent  skin,  with  subsequent  destruction  of  the 
proper  gland  tissue.  Treatment  consists  in  free  incision 
and  the  application  of  strong  disinfectant  solutions. 

B.  Cystic  tumours  of  the  parotid. — Occa- 
sionally the  main  duct  of  the  gland  becomes 
plugged  by  a  calculus,  so  that  the  part  behind  the 
obstruction  and  the  gland  itself  are  distended  to  form  a 
retention  cyst.  This  condition  is,  however,  rare  in 
the  parotid.  In  the  sublingual  region,  salivary 
retention  cysts  are  more  common.  Very  rarely  true 
cysts  (probably  arising  from  the  blocking  of  a  secondary 
duct)  have  been  met  with. 

C.  Solid  tumours  ;  adenoma. — Simple  tu- 
mours in  the  salivary  gland,  composed  of  one  tissue 
only,  are  very  exceptional;  in  almost  every  case  the 
growth  is  compound.  Growths  are  common  in 
the  parotid,  but  rare  in  the  submaxillary  and 
sublingual  glands.  The  ordinary  non-malignant 
"  parotid  tumour "  of  the  older  writers  is  now 
known  to  be  a  fibro-adenoma.  The  adenomatous 
tissue  is  simply  a  co{)y  of  the  original  gland  tissue, 
the  lumen  of  the  acini,  however,  being  filled  up 
with  cells.  Owing  to  changes  in  the  fibrous 
stroma  of  the  tumour,  it  is  frequently  more  correctly 
termed  myxo-adenoma,  and  from  the  not  infrequent 
development  of  cartilage  therein,  is  termed  a  myxo- 
chondro-fibro  adenoma. 

These  simple  parotid  tumours  grow  very  slowly, 
distending  and  usually  rupturing  the  original   capsule 


Parotid  Tumours. 


489 


of  the  gland,  but  forming  a  new  capsule  out  of  the 
surrounding  connective  tissue.  While  growing  in  the 
gland  they  can  often  be  shelled  out  of  this  false  capsule 
without  wounding  the  healthy  gland  tissue.  The  skin, 
too,  is  usually  freely  movable  over  the  mass.  Occa> 
sionally  the  socia  parotidis  is  affected  alone. 

Tlie  most  important  points  to  be  borne  in  mind  in 
connection     with     parotid 
tumours  are  («)  the  facial 
nerve,  and  (6)  the  vascular 
supply. 

{a)  The  facial  nerve 
running  througli  the  lower 
end  of  the  i)arotid  is  liable 
to  the  paralysing  effects  of 
pressure  from  a  new  growth 
of  the  kind  indicated.  But 
it  is  more  liable  to  be  in- 
jured in  removing  the 
tumour,  and  the  possibility 
of  this  accident  (sometimes 
a  necessity)  should  be  ex- 
plained beforehand  to  the 
patient.  {h)  As  regards 
the  blood  supply,  it  is  also 

to  be  remembered  that  the  external  carotid  artery 
passes  through  the  deep  portion  of  the  gland,  but 
no  notice  need  be  taken  of  hremorrhaore  when 
it  IS  a  question  of  thoroughly  removing  a  growth,  all 
vessels  being  secured  with  forceps  as  they  bleed. 
The  internal  maxillary  artery,  will  be  found  to  bleed 
from  both  ends  so  as  to  require  a  double  ligature. 

D.  Adeiio-sarconia  is  a  gi^owth  which  affects 
the  submaxillary  gland  neai-ly  as  often  as  the  parotid  ; 
it  forms  a  steadily  growing  tumour  (the  rate  of  growth 
increasing  with  each  recurrence)  which  becomes  ad- 
herent to  neighbouring  structures,  and  invades  muscles 


Fig.  97. — Adenoma  of  tlie 
Parotid  Gland. 


490  Manual  of  Surgery. 

and  fasciae.  By  pressure  on  the  branches  of  the  fifth 
nerve  it  gives  rise  to  excruciating  pain,  and  penetrates 
deeply  between  the  jaw  and  the  base  of  the  skull.  It 
sometimes  affects  the  glands  secondarily.  Free  ex- 
cision must  be  performed. 

K  Carcinoma  of  the  salivary  g^lands  is 
very  rare  ;  scirrhus  has  been  described  as  most  common. 
An  attempt  to  remove  the  whole  mass  may  be  made  if 
the  disease  be  not  too  far  advanced. 

Y.   Diseases  of  the  Thyroid  Body. 

Up  till  quite  recently  an  account  of  the  diseases  of 
the  thyroid  body  has  been  confined  to  description  of 
goitre  and  its  treatment.  There  seems  good  reason  now 
to  believe  that  the  thyroi'l  gland  may  undergo  active 
atrophic  changes,  accompanied  by  overgrowth  of  its 
stroma,  so  as  to  produce  the  fatal  disease  called  myx- 
oedema;  and,  moreover,  that  the  condition  known  as 
cretinism  results  from  non-development  of  the  gland, 
and  consequently  loss  of  its  function.  A  similar 
parallel  is  to  be  found  in  the  case  of  Addison's  disease, 
which  there  is  very  little  reason  to  doubt  is  simply 
due  to  a  loss  of  the  function  of  the  suprarenal  bodies. 
Both  in  cretinism  and  in  myxcedema  the  thyroid 
gland  is  either  atrophied,  or  the  seat  of  fibro-atrophic 
disease.  The  probable  function  of  the  thyroid  gland,  as 
established  by  experiments  and  clinical  observation, 
concerns,  in  the  first  place,  the  control  of  the  mucinoid 
substances  in  the  tissues  of  the  body,  and  albuminoid 
metabolism  to  some  extent ;  and^  in  the  second  place, 
hsemapoiesis,  i.e.  manufacture  of  blood  corpuscles. 

1.  Atrophy  of  the  thyroid  g^land  is  followed 
by  the  disease  called  myxoedema^  in  which  the  patient 
becomes  lethargic,  the  subcutaneous  tissues  swell  from 
an  accumulation  of  mucus,  and  produce  an  appearance 
like  oedema,  save  that  the  swelling  is  resistent  (the  eye- 
lids and  lips  especially  being  extremely  2>uffy).     The 


Myxcedema. 


491 


blood  becomes  very  anaemic,  there  being  a  loss  of  red 
corpuscles  and  an  increase  of  leucocytes.  The  super- 
ficial vessels  of  the  skin  are  dilated  on  the  cheeks,  etc.; 
and  the  hair,  after  getting  very  thin  and  fine,  falls  out 
rapidly.  The  speech  becomes  thick  and  slow,  and 
the  mental  obfuscation  increases  until  the  patient  gra- 
dually becomes  almost  imbecile.  The  temperature  is 
almost  always  sub- 
normal, and  the 
urine  free  from  al- 
bumin, except  just 
towards  the  end. 
The  general  appear- 
ances are  well  seen 
in  Fig.  98.  This 
condition  has  been 
described  at  some 
length,  for  since  I 
have  produced  ex- 
actly the  same  dis- 
ease in  m  or.  keys  by 
simply  removing 
the  thyroid  gland, 
it  is  now  possible 
to  explain  the  results  obtained  by  Kocher  and  others 
in  extirpating  goitres.  At  the  same  time  there  is 
proof  that  myxcedema  is  the  result  of  atrophy  of  the 
thyroid  body.  Some  hold  to  the  hypothesis  that 
myxcedema  is  in  some  way  or  other  an  affection  of  the 
sympathetic  nerve,  but  on  careful  examination  no 
primary  changes  have  ever  been  found  in  the  sym- 
pathetic, 

2.  Tiiinoiirs  of  the  tli>Toi<l ;  g^oitre  or 
bronchoeole. — Goitres  are  usually  divided  into  two 
classes,  simple  and  exophthalmic.  They  will  here  be 
grouped  under  the  headings  of  congestive  and  neo- 
plastic. 


Fig.  98.— Myxcedema. 


492  Manual  of  Surcfrv. 


A  Consrestive  g:oitres._(a)  The  thyroid  body 
normally  swells  by  congestion  in  the  female  under  the 
influence  of  sexual  excitement  and  pregnancy,  also 
sometimes  during  menstruation.  (6)  It  may  remain 
swollen  and  pulsating  strongly,  so  as  receive  the  name 
ot  vascular  or  pulsating  bronchocele.  Finally  we 
may  have  to  deal  with  the  very  serious  condition 
known  as  exophthalmic  goitre. 

(c)  Exophthalmic  goitre.  ~  This    is    a    variety   of 
goitre  which  has  obtained  special   distinction    owing 
to  the  number  and  prominence  of  the  symptoms.     In 
a    patient  suffering  from    this   condition  the  thyroid 
gland  IS  swollen,  often  tender,   and  pulsating,    4hile 
the    eyes    bulge   out    of    the    orbits,    probably    from 
vascular  dilatation  in  the  loose  tissue  of  those  cavities 
Ihe  protrusion  of  the   eyes    (exophthalmos)   may  be 
so  great  a^  to  cause   conjunctivitis  and  ulceration  of 
the   cornea  from    exposure.      The  patient   is  at  the 
same   time  very  anaemic   and  weak.       The  pulse   is 
lull  and  soft,  and  an  anaemic  murmur  is  often  to  be 
lieard    at    the  base  of  the   heart.     There   is    usually 
amenorrhoea,  loss  of  appetite,  and  prostration.     The 
condition  may  end  fatally ;  or  after  lasting,  as  described, 
for  a   few  months,   gradually  vanish.      Treatment  i^ 
unsatisfactory    since   the    causation    of    the    primary 
congestion  in  the  thyroid  gland  is  unknown.     Iron 
electricity,  etc.,  should  be  tried.  ' 

B.  Neoplastic  goitres.--(a)  The  thyroid  body 
may  undergo  eimple  hypertrophy.  This  sometimes 
follows  simple  congestive  goitre.  The  enlargement 
of  the  gland  IS  both  in  the  stroma  and  proper  gland 
tissue,  so  that  it  is  fibro-adenomatous.  Sometimes 
this  hypertrophy,  which  usually  affects  one  lobe  only 
causes  very  severe  symptoms,  e.g.  breathlessness  on 
exertion,  famtness  and  giddiness,  trembling  and 
weakness  m  the  limbs;  but  as  a  rule,  if  actively 
treated,  it  gradually  disapj^ears.     The  mass  should  be 


Goitre, 


493 


painted  with  iodine,  or  an  ointment  of  oleate  of  mer- 
cury (2  per  cent.)  and  morphia  (5  per  cent.)  he 
rubbed  into  the  skin  covering  it.  At  the  same 
time  quinine  and  iron  should  be  administered  in  full 
doses. 

(Jj)  Fibrous  goitre  is  the  name  frequently  given 
to  the  mass  when  the  stroma  grows  at  the  expense  of 
the  proper  gland  tissue.  It  is  a  convenient  term  if  it 
is  understood  that  the 
tumour  is  really  a  large 
fibro-adenoma,  and  that 
it  may  be  very  soft  and 
vascular  (then  of  rapid 
growth),  or  it  may  be 
chronic  and  of  dense 
structure.  As  with  sim- 
ple hypertro|)hy,  this 
disease  usually  affects 
one  lobe  (more  com- 
monly the  right),  and 
according  to  the  ra- 
pidity of  growth  pro- 
duces more  symptoms 
(Fig.  99).    It  gradually 

forces  the  trachea  to  the  opposite  side,  flattening  it  so 
as  to  diminish  its  calibre  ;  growing  backwards  it  pushes 
the  carotid  artery  and  jugular  vein  with  the  vagus 
nerve  even  into  the  posterior  triangle.  It  stretches 
the  above-mentioned  structures,  which  usually  become 
adherent  to  the  capsulf'  of  the  tumour.  The  tumour 
itself  is  situated  beneath  the  deep  fascia,  and  is 
surrounded  by  the  loose  tissue  of  the  neck.  Owing 
to  its  relations  to  the  trachea  (the  isthmus  being 
fixed  to  that  tube  by  a  firm  layer  of  fascia),  the 
tumour  rises  and  falls  with  every  effort  at  swallowing 
which  the  patient  makes,  a  diagnostic  sign  of  the 
greatest   value.       The   vessels  are  often   enormously 


Fig.  99. — Fibrous  Goitre. 


494  Manual  of  Surgery. 

enlarged,  the  thyroid  arteries   being  sometimes  one- 
third  of  an  inch  in  diameter. 

(c)  Cystic  goitre.  —  Before  describing  the  treat- 
ment of  fibrous  goitre,  it  will  be  best  to  mention  the 
cystic  condition.  Cystic  goitre  is  simply  fibro- 
adenomatous  goitre,  in  which  large  cysts  appear 
derived  from  the  acini  of  the  gland.  The  contents  of 
these  cysts  are  usually  fluid,  serous,  bloody,  or  col- 
loidal. They  sometimes  attain  a  large  size,  making  up 
most  of  the  mass  of  the  tumour.  The  walls  of  the 
cysts  are  frequently  extremely  vascular,  and  in  long- 
standing cases  calcified. 

Treatment  of  g^oitre. — If  slow  growing,  in- 
unction of  mercury  or  iodine  may  be  tried  first. 
If  these  fail  and  the  mass  is  cystic,  then  injection  of 
iodine  or  of  iodide  of  potassium  or  perchloride  of  iron 
into  the  substance  of  the  growth  or  into  a  cyst 
may  be  employed.  Great  care  must  be  taken  to 
avoid  puncturing  a  vein,  as  the  dii'ect  injection  of  most 
of  the  above  fiuids  into  the  blood  stream  is  a  fatal 
accident.  After  the  canula  is  inserted,  a  delay  should 
be  made  before  injecting,  to  see  if  a  stream  of  blood 
flows  out  indicating  wound  of  a  vessel.  If  the 
tumour  is  very  soft  and  rapidly  growing,  injection 
sometimes  produces  violent  inflammatory  mischief, 
leading  to  cellulitis  of  the  neck  and  abscess.  Removal 
of  the  whole  goitre  is  a  successful  operation  when  per- 
formed antiseptically,  but  should  be  confined  to  one 
lobe  only.  Kocher  showed  that  complete  removal  of 
both  lobes  was  followed  by  myxoedema.  This  he  thought 
was  a  result  of  chronic  asphyxia  or  injury  of  the  sympa- 
thetic ;  but  my  experiments  above  referred  to  show  that 
it  is  due  to  loss  of  the  function  of  the  gland.  Moreover, 
the  removal  of  one  lobe  causes  atrophy  of  a  tumour  in 
the  other,  and  excision  of  the  isthmus  relieves  pressure 
symptoms,  and  also  causes  atrophy  of  the  growth,  so 
that  these  operations  are  alone  justifiable. 


Scalds  of  Larynx.  495 

VI.  Affections  of  the  Larynx  and  Trachea. 

Fractures  aud  scalds  of  the  lar>nax  aud 
tracliea. — Contusions  and  wounds  of  the  larynx  and 
trachea  have  already  been  referred  to.  There  remain 
then  fractures  and  scalds  of  those  parts  for  consideration. 
As  cadeina  glottidis  plays  a  most  important  part  in  de- 
ciding the  nature  and  treatment  of  these  cases,  a  few- 
words  may  be  added  to  what  has  already  been  said  at 
page  475.  In  the  first  place  it  must  be  noted  that  oedema 
of  the  glottis  may  come  on  "  idiopathically,"  i.e.  in 
some  cases  of  Bright's  disease.  Occurring  in  middle-aged 
men,  it  is  not  very  uncommon  to  find  that  the  patient  is 
seized  with  rapidly  increasing  difficulty  of  breathing, 
requiring  to  be  sat  up  in  bed,  using  all  the  extra 
muscles  of  respiration,  and  becoming  cyanotic.  In 
these  cases  the  mucous  membrane  of  the  pharynx  and 
larynx  (especially  the  loose  aryteno-epiglottic  folds) 
becomes  enormously  swollen  from  rapid  transudation 
of  fluid  into  the  submucous  tissue,  and  it  is  this 
swelling  which  blocks  up  the  entrance  to  the  glottis, 
and  so  causes  dyspncea.  If  met  with  early,  this  so- 
called  idiopathic  oedema  (exactly  the  same  thing  is 
seen  in  wasp  or  bee  stings  of  the  back  of  the  throat) 
can  sometimes  be  got  rid  of  by  causing  the  patient  to 
inhale  steam  as  hot  as  it  can  be  borne,  but  it  often 
requires  operative  interference.  Scarification  of  the 
aryepiglottic  folds,  performed  by  scoring  the  mucous 
membrane  with  a  curved  probe-pointed  bistoury,  is 
sometimes  followed  by  complete  relief  as  the  fluid  and 
blood  flow  out  of  the  cuts.  As  a  rule,  however, 
laryngotomy  must  be  performed;  without  an  an- 
aesthetic (or  with  preliminary  freezing  of  the  skin) 
for  these  cases  which  are  specially  liable  to  fatal  syncope 
which  might  be  induced  by  chloroform. 

Scalds  of  the  pharynx  and  larynx  pro- 
duce the  same  condition  mure  lapidly.     The   boiling 


49^  Manual  of  Surgery, 

water  taken  into  the  moutli  from  a  kettle  is  not 
swallowed,  but  ejected  by  the  violent  spasm  of  the 
pharynx.  However,  the  scalded  membrane  instantly 
becomes  violently  congested,  and  oedema  sets  in. 
Tracheotomy  must  be  performed  if  the  symptoms  of 
asphyxia  rapidly  increase,  and  if  hot  inhalations  have 
proved  useless.  Syncope  is  also  common  in  these 
cases  owing  to  the  acuteness  of  the  asphyxial  cou- 
ditioiL  Often,  if  the  child  escape  the  primary  evils 
just  described,  the  pharynx  and  larynx  become  the 
seat  of  a  fibrinous  exudative  inflammation  which  has 
been  called  croupous  since  the  mucous  membrane  is 
covered  with  a  white  fibrinous  false  membrane.  Pre- 
cisely the  same  condition  may  arise  from  a  person 
swallowing  strong  acids. 

Fractures  of  the  larynx  are  very  fatal  ac- 
cidents. The  thyroid  cartilage  is  usually  separated 
into  its  two  halves,  and  the  hyoid  bone  is  not  in- 
frequently broken  at  the  same  time,  under  which  cir- 
cumstance movement  of  the  tongue  becomes  very  pain- 
ful, and  the  voice  is  so  altered  as  to  be  unintelligible. 
Fracture  of  the  larynx  may  be  immediately  fatal 
from  dislocation  of  the  vocal  cords,  and  consequent 
asphyxia  from  spasm  of  the  glottis.  Or,  again,  if  the 
mucous  membrane  is  torn  the  person  may  be  choked 
with  blood;  evidence  of  wound  of  the  membrane  being 
afforded  by  his  coughing  up  bloody  mucus.  Finally, 
Oidema  glottidis  may  set  in  at  any  time,  soon  after 
the  accident.  Tracheotomy  should  therefore  be  per- 
formed as  a  prophylactic  measure  in  all  cases  of  bad 
fracture  of  the  larynx.  Treatment  should  be  limited 
to  relieving  symptoms,  and  attempting  to  fix  the 
fragments  together  by  strapping  the  neck  lightly  ;  or 
if  the  displacement  is  severe,  they  should  be  cut  down 
upon  and  united  with  catgut. 

Foreig^ii  bodies  in  the  air  passages. — The 
substances    which    may  find    their    way  into  the  air 


Foreign  Bodies  in  Larynx,  497 

passages  are  very  various  and  numerous,  but  the 
symptoms  produced  are  so  very  much  alike  that  a 
diagnosis,  in  most  cases,  is  comparatively  easy.  First, 
as  regards  their  entry  into  the  air  passage,  it  will  not 
be  forgotten  that,  in  order  to  reach  the  trachea,  a 
foreign  body  must  pass  through  the  rim  a  glottidis, 
the  least  touch  of  either  side  of  which  naturally  ex- 
cites a  severe  spasm  of  the  glottis,  and,  consequently, 
such  a  body  can  get  into  the  trachea  only  when  the 
glottis  is  widely  open.  This  happens  when  a  person 
holding  a  body  loosely  in  the  mouth  gives  a  sudden 
violent  inspiration.  The  foreign  body  is  then  sucked 
into  the  air  passage.  A  foreign  body  may  be  im- 
pacted in  the  larynx  above  or  between  the  vocal 
cords,  very  commonly  above,  being  caught  in  the 
mouth  of  the  laryngeal  pouches  or  sacs  on  either 
side.  Xext,  it  may  be  loose  in  the  trachea,  and, 
finally,  may  drop  down  into  a  bronchus,  usually  the 
right  one,  because  that  is  in  a  more  direct  line  with 
the  axis  of  the  trachea  than  is  the  left.  The  symp- 
toms of  a  foreign  body  in  these  different  regions  of 
the  air  passage  vary,  as  does  also  the  treatment. 

Impaction  in  the  larynx. — The  presence  of  a 
foreign  body  in  the  larynx  usually  causes  violent 
spasm  of  the  sphincter-like  muscles  of  the  larynx,  so 
that  the  patient  just  after  the  accident  is  in  imme- 
diate danger  of  death  from  asphyxia ;  in  fact,  the 
majority  of  patients  die  at  once  if  the  mass  impacted  is 
cylindrical  and  too  large  to  go  through  the  rima  glotti- 
dis. Such  instances  are  seen  in  cases  where  a  person 
has  "bolted  "  large  pieces  of  meat  and  one  has  slipped 
beneath  the  epiglottis.  If,  however,  the  foreign  body 
is  thin  and  flat,  albeit  very  angular  and  sharp,  the 
patient  will  probably  recover  from  the  first  severe 
spasm  of  the  glottis,  and,  as  air  can  pass  freely. past 
the  body,  he  will  survive  the  accident,  having,  how- 
ever, severe  attacks  of  spasm  at  intervals,  with 
G  G— 21 


498 


Manual  of  Surgery. 


exhausting  cough,  and  expectorating  blood-stained 
mucus.  This  accident  is  to  be  feared,  as  specially 
tending  to  asphyxial  syncope  from  failure  of  the  heart, 
a  very  fatal  form  of  fainting.  Examination  of  the 
larynx  with  the  lar^aigoscope  must  be  made  at  once, 
and,  if  the  body  is  seen  at  the  top  of  the  larynx  fixed 
in  the  aryepiglottic  fold,  it  should  be  seized  with 
laryngeal  forceps  and  withdrawn  (Fig.  100).    If  deeply 

impacted,  laryngotomy  must  be 
performed,  and  thyrotomy  car- 
ried upwards  for  half  an  inch 
or  so,  and  the  foreign  body  ex- 
tracted with  as  little  laceration 
of  the  mucous  membrane  as 
possible.  After  thorough  cleans- 
ing of  the  parts  a  laryngotomy 
tube  should  be  kept  in  for 
twenty-four  to  forty -eight  hours, 
until  danger  of  oedema  glottidis 
has  passed  away. 

Under  certain  circumstances, 
e.g.  narrowness  of  the  foreign 
body,  etc.,  persons  may  tolerate 
the  pressure  of  a  foreign  body  in  the  larynx  for  months. 
Foreign  body  loose  in  the  trachea.  —  This  con- 
dition of  things  is  perhaps  the  most  trying  to  a 
patient,  for  two  reasons.  Firstly,  the  body,  being 
loose,  is  coughed  up  against  the  lower  surface  of  the 
rima  glottidis;  this  excites  powerful  spasm  of  the 
glottis,  with  accompanying  asphyxial  symptoms  of 
greater  or  less  severity.  Secondly,  the  presence  of 
the  loose  body  excites  free  secretion  from  the  air 
tubes  of  a  quantity  of  frothy  mucus,  which  also 
suffocates  the  patient.  In  one  instance  I  saw  a 
plug  of  tenacious  mucus  itself  produce  urgent  symp- 
toms by  being  driven  against  the  glottis  until  it  was 
removed    by  tracheotomy.      A  patient   suffering   as 


Fig.  100.— Fish  Bone    im- 
pacted in  Larynx. 


Foreign  Bodies  in  Larynx.  499 

above  sits  propped  up,  the  air  entering  the  chest 
badly,  owing  to  the  filling  up  of  the  tubes,  so  that  the 
face  is  livid  and  the  respirations  very  laboured.  On 
auscultation  little  air  will  be  found  to  get  to  the  bases 
of  the  lungs,  and  the  air  tubes  will  be  full  of  loud 
mucous  rattling  rales.  Simple  acute  bronchitis  being 
excluded  by  the  history,  tracheotomy  must  be  done  at 
once ;  ancl,  instead  of  a  tube  being  inserted,  it  is 
best  to  pass  a  carbolised  silk  loop  through  each  side  of 
the  tracheal  wound,  so  that  it  can  be  drawn  open  and 
the  escape  of  a  foreign  body  facilitated,  thus  avoiding 
the  hindrance  necessarily  offered,  to  a  large  extent, 
by  the  presence  of  a  tube.  A  dilator  (Golding  Bird's) 
is  also  used  for  the  same  purpose.  The  mucus  should 
be  aspirated  or  sucked  out  of  the  trachea  as  soon 
as  the  latter  is  opened.  When  the  air  passage  is 
fairly  free  the  patient  may  be  inverted  gradually 
and  encouraged  to  cough ;  the  body,  if  loose,  will 
probably  then  be  expelled  through  the  larynx  or 
wound.  It  is  imperative  obviously  to  perform  tracheo- 
tomy when  the  symptoms  of  laryngeal  spasm  are  re- 
curring, but  now  it  must  be  stated  that  the  operation 
should  always  be  performed  as  a  prophylactic  measure 
if  the  diagnosis  is  clear;  and  a  paroxysmal  attack 
of  laryngeal  spasm  is  unmistakable.  It  should 
be  performed  because  the  expulsion  of  the  body 
is  rendered  quite  safe,  since  the  patient  can 
breathe  in  spite  of  the  spasm  above.  This  treatment 
is  strongly  supported  by  statistics,  which  have  con- 
siderable value  in  a  question  like  the  present. 
Foreign  bodies  have  been  expelled  naturally  even  as 
long  as  nine  months  after  the  accident,  but  usually 
the  end  of  the  case  is  much  less  favourable. 

Impaction  in  a  bronchus^  usually  the  right  one. 
— This  condition  will  be  preceded  by  such  symp- 
toms as  have  been  just  described.  Special  symptoms 
are :    Pain   at  seat  of   lodgment,    no    breath   sounds 


500 


Manual  of  Surgery. 


in  Inng,  whistling  rales  at  seat  of  impaction, 
especially  if  the  body  is  tubular,  purulent  bronchitis, 
followed  by  abscess  in  the  lung  very  frequently,  and 

more  rarely  phthisis. 
An  attempt  should  be 
made  to  extract  the 
body  by  passing  down 
the  trachea  a  wire  hook 
and  fine  forceps,  the 
patient  being  fully  an- 
aesthetised. 

Tumours  of  the 
larynx  may  very  well 
be  considered  next,  since 
the  symptoms  they  give 
rise  to  are  practically 
those  of  foreign  bodies. 
They  are  popularly 
grouped  together  as 
polypi.  They  consist  of 
the  following  kinds,  the 
commoner  being  men- 
tioned first  : 

1.  Fapillovm,  or 
wart,  consists  of  a  fibrous 
framework  covered  with 
thin  mucous  membrane. 
Laryngeal  papillomata 
are  frequently  multiple, 

sometimes  sessile,  at  other  times  pedunculated  (Fig. 

101).     In  children  these  may  grow  to  a  large  extent 

and  cause  chronic   asphyxia,   for  which  tracheotomy 

has   been   resorted   to    in    ignorance    of    the   cause. 

Thyrotomy  is  the  operation  to  be  performed. 

2.   Fibroma. — A  roundish  smooth  tumour,  usually 

sessile,    composed   of  simple    fibrous  tissue   growing 

from  the  submucosa. 


Fig.  101. — Lai'yngeal  Papilloma. 


Tumours  of  Larynx.  501 

3.  Adenoma. — A  solid  tumour,  which  begins  in  the 
mucous  glands  and  grows  in  the  submucosa. 

4.  Epithelionw,  rather  commoner  than  the  last, 
is  like  epithelioma  elsewhere.  The  disease  sjDreads 
iintil  it  destroys  the  surrounding  tissues,  sometimes 
appearing  on  the  surface  of  the  neck  as  a  fungating 
sore.  The  ulcer  presents  the  typical  raised  thick  and 
hard  border,  with  dirty  granulation  tissue  forming 
the  floor.  It  implicates  surrounding  tissues,  and  in- 
fects the  neighbouring  lymph  glands. 

5.  Myxoma.  —  Myxomatous  polypi  are  found 
sometimes  in  the  larynx. 

The  above  tumours  grow  very  slowly,  as  a  rule, 
and,  if  high  up  in  the  larynx,  cause  practically  no 
symptoms  until  of  considerable  size.  As  a  rule  they 
produce  alteration  in  the  voice,  coughing,  and,  in 
severe  cases,  attacks  of  paroxysmal  dyspnoea.  They 
are  detected,  of  course,  by  the  laryngoscope,  and  their 
early  removal  effected.  This  may  be  done  in  two 
ways.  Either  the  growth  may  be  seized  with 
laryngeal  forceps,  snare,  or  galvanic  cautery  (the 
larynx  being  partly  ana3sthetised  with  cocaine), 
and  the  instrument  guided  by  means  of  the  laryngo- 
scope ;  or  the  thyroid  cartilage  must  be  split  and 
the  larynx  examined.  The  former  operation  is  styled 
endo-laryngeal,  and  requires  no  further  mention  here ; 
but  a  few  words  must  now  be  said  on  thyrotomy. 

Thyrotomy. — The  patient  being  anaesthetised,  and 
the  shoulders  raised  and  the  neck  stretched,  the 
anterior  border  of  the  thp-oid  cartilage  and  the  crico- 
thyroid membrane  are  exposed  by  free  incision.  All 
bleeding  having  been  stopped,  the  crico-thyroid  mem- 
brane is  opened  for  a  short  distance,  and  then  the 
thyroid  cartilage  is  split  up  to  the  top  quarter  inch, 
which  is  left  intact  to  prevent  gliding  displacement  of 
the  two  halves.  The  two  halves  being  now  separated, 
the  interior  of  the  larynx  is  inspected,  and  all  growths 


502  Manual  of  Surgery. 

removed.  As  the  mucous  membrane  is  "sery  sensitive 
axid  reflex  action  vigorous,  it  is  best  to  first  paint  it 
with  cocaine  solution,  10  to  20  per  cent.  (Parker)^  and 
then  snip  off  the  growths.  All  bleeding  can  be 
arrested  by  pressure,  and  then  the  sides  of  the  thyroid 
must  be  stitched  toirether  with  fine  catsrut  and  the 
wound  closed,  except  opposite  the  crico-thyroid  o[)ening. 
A  light  dressing  of  carbolic  gauze  should  be  applied. 

Excision  of  the  larjiix.— If  the  new  growth 
is  epithelioma,  the  larjTix  must  be  excised,  the 
operation  being  performed  in  the  following  way  :  A 
free  incision  is  made  through  the  superficial  struc- 
tures, and  through  the  deep  fascia  from  the  hyoid 
bone  to  opposite  the  third  tracheal  ring ;  the  trachea 
is  then  laid  bare  above  the  isthmus  of  the  thyroid 
gland  (which  is  drawn  downwards),  freed  from  the 
oesophagus,  and  finally  cut  across  at  the  second 
ring  and  the  open  lower  end  plugged  with  a  tampon 
tube,  through  which  the  anaesthetic  can  be  admini- 
stered, and  which  at  the  same  time  allows  no  blood 
to  trickle  into  the  windpipe. 

The  larynx  is  then  freed  on  each  side,  the  edge  of 
the  knife  being  kept  turned  towards  the  part  to 
be  removed.  In  doing  this  the  superior  laryngeal 
arteries  will  require  ligature.  The  larynx  is  now 
separated  from  the  hyoid  bone,  and  finally  from  the 
front  of  the  pharynx.  The  wound  .should  be  mopped 
out  with  chloride  of  zinc  (40  gr.  to  5j)  and  dusted  with 
iodoform.  The  dressing  should  be  a  light  one  of 
gauze  or  wool.  The  patient  to  be  fed  by  nutrient 
enemata  as  long  as  possible,  and  then  by  a  tube. 
When  the  wound  is  healed,  Gussenbauer's  or  Foulis's 
artificial  larynx  is  inserted  into  the  gap  so  that  the 
patient  can  talk  distinctly. 

L.ar}Tig:itis  Mith  especial  reference  to 
croup,  diphtheria,  and  the  operation  of  trach- 
eotomy*— There  are  several  conditiona  of  the  larynx 


Laryngitis.  503 

to  be  here  noted  which  are  usually  termed  laryngitis, 
but  the  pathological  state  of  which  is  really  spe- 
cific. Bearing  this  in  naind  we  may  enumerate 
the  varieties  of  laryngitis  as,  (a)  acute  laryngitis  ; 
(6)  chronic  laryngitis  ;  (c)  croupous  laryngitis  ; 
\d)  diphtheritic  laryngitis;  (e)  tubercular  laryngitis ; 
(  0  syphilitic  laryngitis. 

(a)  Acute  laryngitis  of  a  simple  character  pro 
duces  symptoms  like  oedema  glottidis,  for  the 
simple  reason  that  the  latter  is  present,  but  are 
not  so  urgent,  since  the  causation  is  simpler. 
Acute  laryngitis,  started  by  catarrh,  and  causing  hoarse- 
ness and  loss  of  voice,  is  sometimes  succeeded  by 
urgent  symptoms  of  dyspnoea,  etc.  It  can  usually  be 
controlled  by  the  simple  application  of  hot  fomenta- 
tions (mustard,  etc.)  to  the  outside  of  the  neck, 
coupled  with  steam  and  benzoin  inhalations,  the 
patient  being  kept  in  a  warm  room,  and  well  fed 
up. 

(6)  Chronic  laryngitis,  evidenced  by  hoarseness  and 
soreness,  with  hawking  up  of  mucus,  etc.,  is  to  be 
treated  laryjjgoscopically  with  astringent  lotions 
applied  by  a  proper  brush. 

(c  and  d)  Croup  and  diphtheria  are  regarded  by 
many  as  degrees  of  the  same  disease,  viz.  a  mem- 
branous intlammation,  i.  e,  an  inflammation  in 
which  there  is  exuded  on  the  surface  of  the 
mucous  membrane  a  fibrinous  exudation  which  forms 
a  white  false  membrane.  This  false  membrane  may 
be  easily  detached  in  a  mild  case  of  croup,  or  is  firmly 
adherent  to  a  raw  bleeding  surface  in  a  bad  case  of 
diphtheria.  Croup  very  often  attacks  a  child  sud- 
denly, with  an  incubation  period  of  only  a  few  hours 
elapsing  before  the  characteristic  brassy  cough  is  heard, 
and  dyspnoea  follows.  Diphtheria  as  a  rule  is  pre- 
ceded by  some  days  of  malaise,  and  the  throat 
symptoms  often  take  a  good  many  hours  to  develop. 


504 


Manual  of  Surgery, 


The  inflammation  of  the  mucous  membrane,  followed 
by  the  growth  of  the  membrane,  passes  upwards  into 
the  nose  (when  it  is  nearly  always  fatal)  and  down- 
wards  into   the  larynx,  forming  sometimes  a  perfect 

cast  of  the  air  passages 
(Fig.  102).  In  the  latter 
case  it  produces  the  clas- 
sical signs  Q.f  laryngeal 
obstruction.  There  is  one 
symptom,  however,  that 
forms  a  strong  indication 
for  the  performance  of 
tracheotomy,  and  that  is 
the  recession  of  the  soft 
parts  about  the  chest  walls 
when  the  patient  makes 
efforts  at  inspiration. 
When  this  is  marked, 
tracheotomy  is  to  be  per- 
formed at  once. 

{e  and  f)  Tubercular 
and  syj)hilitic  laryiigitis 
are  the  names  given  to 
tubercular  and  syphilitic 
congestion  and  ulceration 
of  the  larynx.  The  ulcers 
are  in  both  cases  ragged 
sores,  the  edges  raised, 
and  the  floor  sloughy.  In 
tubercular  disease  there  is 
usually  chronic  cedema,  and  in  syphilis  gummatous 
masses  are  often  seen.  Tubercular  laryngitis  is 
usually  very  painful  and  fatal,  and  traclieotomy 
affords  but  slight  relief.  As  syphilitic  ulceration 
heals,  the  cicatrices  often  contract  the  larynx  so 
much  as  to  necessitate  the  operation. 

TrsLclicotonay    is  one  of  the    most    important 


Fig.    102. — Memb)-anous    cast    of 
Trachea    aud    Bronchi  from  a 
case     of    Diphthci'ia. 
Lond.  Hosp.  Museum.) 


(From 


Tracheotomy. 


505 


"emergency"  operations,  and  therefore  one  always  to 
be    done    with    every     precaution    and    deliberation 
if    tliere    is    reasonable     time.       The     shoulders     are 
to   be    raised  on  a  firm  small  pillow,   the  neck  and 
head  thrown  back,  the  former  resting  in  a   hollow   in 
a  sand-bag,  which  fixes  it  and  prevents  it  rolling  from 
side  to  side.  An 
assistant,     hold- 
ing his  fore-arms 
on  each  side  of 
tiie  child's  head, 
is  ready  to  open 
the  w^ound  with 
blunt  hooks.  An 
incision   is  then 
to  be  made  ex- 
tending     from 
the  crico-thyroid 
membrane  to  a 
variable  distance 
above  the    ster- 
num.   The  ante- 
rior jugular  vein 
being    "  avoided 
(Fig.    103),    the 
deep     fascia     is 
opened    to    the    same    extent  as    the    skin,    the    de- 
pressor   muscles   of    the    hyoid     are    then    exposed 
and    the    fascial    septum   between  them  incised,  and 
the    muscles    held   apart    by  the    hooks.      The   loose 
connective    tissue     covering     the     isthmus     of     the 
thyroid   is    divided,    and   the  isthmus    drawn    down- 
wards with  a  blunt  hook,  the   trachea  being  exposed 
then  between  it  and  the  cricoid  cartilage  by  a  few 
more  touches  of  the  knife.      A   small  sharp  hook   is 
now  stuck  into  the  front  surface   of  the  windpipe  to 
steady   it   while   it    is    opened    carefully    with    the 


Fig.  103. — Median  line  of  Neck. 

L.  Larynx  ;  c,  cricoid  cartilage  ;  T,  trachea  ;  Th,  thy- 
roid glaud. 


5o6  Manual  of  Surgery. 

scalpel,  the  back  being  towards  the  thyroid  isthmus. 
Directly  it  is  opened,  the  sides  of  the  wound  in  tho 
trachea  must  be  held  apart,  and  all  mucus  and  false 
membrane  cleared  out  by  feathers,  or  aspirated 
by  a  soft  catheter  and  syringe.  When  clear,  the 
tube  is  to  be  inserted,  and  tied  in.  A  little  carbo- 
lised  vaseline  may  be  rubbed  gently  on  the  wound 
before  the  tube  is  put  in. 

Complications. — The  operation  is  usually  much 
more  difficult  than  just  described,  the  patient  strug- 
gling for  breath,  vessels  oozing,  etc.  Chloroform  pre- 
vents such  struggling  (but  very  little  is  required), 
serious  bleeding  is  stopped  by  forceps  as  the 
operation  proceeds,  oozing  always  ceasing  when 
respiration  is  re-established.  After  the  operation  the 
tube  wants  constant  attention.  The  wound  may 
become  sloughy,  the  neck  emphysematous,  oedematous, 
or  erysipelatous.  .  Attempts  should  be  made  to  do 
without  the  tube,  beginning  on  the  fifth  day  by 
stopping  the  mouth  of  the  tube,  and  then  leaving  it 
out  for  a  few  minutes,  increasing  the  interval  every 
day.  The  operation  is  of  value,  not  only  by  relieving 
the  asphyxia,  but  because  it  enables  the  operator 
to  thoroughly  clear  out  the  larynx,  this  being  done  by 
passing  a  feather  up  from  the  wound,  or  passing  a 
string  into  the  mouth  and  drawing  small  plugs  of 
antiseptic  wool  up,  as  sponges.  If  the  tube  and 
wound  tend  to  dry,  so  that  the  discharge  blocks  it, 
then  the  steam  kettle  must  be  used  to  keep  the 
air  moist,  and  at  the  same  time  the  membrane  must 
be  softened  with  solution  of  carbonate  of  soda  and 
glycerine. 


5°? 


XiJ.     DISEASES    OF    THE    NOSE   AND 
NASAL   CAVITIES. 

William  J    Walsham. 

IVouiids  of  the  nose  may  be  inflicted  from 
without,  or  from  within  through  the  nostrils ;  they 
may  merely  involve  the  superficial  structures,  or  they 
may  be  complicated  by  division  of  the  cartilages,  or 
fracture  of  the  bones.      {See  Art.  i.,  vol.  i.) 

The  parts  should  be  thoroughly  cleansed,  and 
brought  as  accurately  together  as  possible  with  horse- 
hair sutures,  and  the  wound  sealed  with  collodion. 
Even  where  considerable  portions  of  tissue  have  been 
detached,  immediate  union  may  be  hoped  for,  as  the 
blood  supply  of  the  nose,  like  that  of  the  face  generally, 
is  very  free,  a  fact  wdiich  also  explains  the  liability  of 
wounds  of  these  parts  to  be  followed  by  swelling  or 
erysij)elas ;  but  if  much  tissue  has  been  lost,  a  plastic 
operation  may  be  subsequently  requrred.  When  a 
sharp  instrument  has  been  thrust  up  the  nostril,  care 
should  be  taken  that  no  portion  of  it  is  allowed  to 
remain  in  the  wound  ;  and  as  in  such  cases  the  cranium 
may  have  been  penetrated  and  the  brain  injured,  rest 
sliould  be  enjoined  and  the  patient  watched  for  any 
signs  of  intracranial  inflammation. 

£pistaxis,  or  bleeding  from  the  nose,  is  a  common 
attendant  on  blows  or  other  injuries,  and  is  a  promi- 
nent symptom  of  certain  forms  of  fracture  of  the  base 
of  the  skull  and  of  fibrous  and  malignant  growtlis  in 
the  nose  or  naso-pharynx.  It  frequently  occurs  spon- 
taneously. Thus,  in  children  and  young  adults  it  is 
often  due  to  congestion  of  the  mucous  membrane,  and 
is  especially  common  in  girls  about  the  age  of  puberty. 
In  the  middle-aged  it  appears  to  be  due  to  plethoric 


5o8  Manual  of  Surgery. 

habit  and  congestion  of  the  brain  and  liver.  In  the 
old  or  cachectic  it  may  depend  upon  a  poor  condition 
of  the  blood,  such  as  occurs  in  cirrhosis  of  the  liver, 
granular  kidney,  heart  disease,  scurvy,  and  in  some 
fevers.  The  blood  usually  escapes  from  one  or  other 
nostril,  but  may  pass  through  the  posterior  nares  and 
the  gullet  into  the  stomach,  and,  being  afterwards 
vomited,  may  simulate  haematemesis,  or  it  may  irritate 
the  larynx  and  be  coughed  up  in  a  frothy  condition 
and  be  mistaken  for  haemoptysis.  Some  florid  blood, 
however,  will  generally  escape  from  the  nostril  at  the 
same  time,  and  can  usually  be  seen  trickling  down  the 
back  of  the  throat. 

Treatment. — For  an  account  of  the  treatment 
required  for  the  various  conditions  that  may  give  rise 
to  epistaxis  the  reader  is  referred  to  other  portions  of 
this  work,  or  to  a  treatise  on  medicine.  Here  it  will 
suffice  to  indicate  the  means  that  may  have  to  be 
adopted  for  arresting  the  bleeding  when  this  is  thought 
advisable.  When  the  result  of  a  blow  or  other  injury 
of  the  nose,  or  occurring  spontaneously  in  the  young, 
the  hajmon-hage  generally  ceases  of  its  own  accord,  or 
may  be  readily  controlled  by  cold  sponging,  elevation 
of  the  arms_,  and  other  well-known  domestic  remedies ; 
whilst  in  the  plethoric,  as  the  result  of  congestion,  it 
should  not  be  too  hastily  checked,  as  it  may  prevent 
graver  mischief,  such  as  cerebral  haemorrhage.  In  the 
old  and  cachectic  the  arrest  of  the  bleeding  is  generally 
indicated,  but  may  be  attended  with  difficulty.  Rest, 
the  sucking  of  ice,  an  ice  bag  to  the  bridge  of  the  nose, 
cold  to  the  spine,  and  cold  douches,  with  the  internal 
administration  of  gallic  acid,  lead  and  opium,  ergot  or 
perchloride  of  iron,  may  be  tried.  These  means  failing, 
it  may  be  necessary  to  plug  the  nares.  This  may  be 
done  either  with  the  inflating  tampon,  or  with  pledgets 
of  lint  or  iodoform  wool.  An  inflating  tampon  is 
shown  in  Fig.  104.    It  consists  of  an  indiarubber  tube 


Epista  xjs. 


509 


with  two  dilatations  upon  it,  so  sized  and  shaped  that 
when  inflated  they  may  accurately  fill  the  anterior  and 
posterior  nares  respectively.  It  is  passed  through  the 
nostril  in  a  flaccid  condition  by  means  of  a  long  probe, 
and  the  air  after  inflation  prevented  from  escaping  by 
twisting  and  clamping  the  tube.  To  ])lug  the  posterior 
nares  with  lint  or  cotton  wool,  a  pledget  should  be 
made  about  the  size  of  the  last  joint  of  the  thumb,  and 
secured  round  the  middle  by  a  piece  of  twine  which 
has  been  preWously  passed  through  the  nostril,  round 
the  palate,  and  out  of  the  mouth  by  means  of  a 
Bellocq's  sound,  or  if 
this  is  not  at  hand,  by 
a  gum  elastic  catheter. 
The  plug  can  be  then 
drawn  into  the  posteiior 
nares  by  making  trac- 
tion on  the  end  of  the 
string  protruding  from 
the  nostril,  aided  by  the 
fore-flnger  behind  the  palate.  I  have  found,  however, 
that  the  patient  is  less  inconvenienced  by  pushing  a 
piece  of  fine  soft  rubber  tubing  along  the  floor  of  the 
nose,  and  when  it  presents  below  the  palate,  drawing 
it  forwards  by  the  forceps  and  securing  it  to  the  twine 
already  attached  to  the  pledget.  Tlie  anterior  nares 
may  next  be  plugged  by  a  similar  pledget,  secured  by 
the  thread  already  hanging  out  of  the  nostril.  The 
other  end  of  the  string  attached  to  the  posterior  plug 
may  be  fastened  loosely  to  the  cheek  or  allowed  to  fall 
backwards  into  the  pharynx,  and  will  be  of  service  in 
the  removal  of  the  plug. 

Foreign  bodies,  such  as  peas,  beads,  etc.,  are 
often  pushed  up  the  nostril  by  children,  and,  more 
rarely,  hard  substances  such  as  cherry-stones  and  the 
like  have  during  vomiting  entered  into  the  nasal 
cavities  from  behind  the  palate.     They  may  remain  in 


Fig.  104.  —  Indianibber  inflating 
Tampon  for  plug^int?  the  Nares  in 
Epistaxis.     (Arnold's  Catalogue.) 


5IO  Manual  of  Surgery. 

the  nasal  passages  for  some  time  witliout  being  dis- 
covered, but  the  foetid  discharge  to  which  they  almost 
inevitably  sooner  or  later  give  rise  should  lead  to  a 
suspicion  of  their  presence.  They  can  generally  be 
extracted  by  the  forceps,  or  by  some  of  the  ingenious 
screws  or  curettes  invented  for  the  purpose ;  or  they 
may  be  freed  by  the  nasal  douche  sent  up  one  nostril 
and  returned  by  the  other  ;  but  Rouge's  operation  has 
sometimes  been  necessary  for  their  removal. 

l&liinolitlis,  or  nose  stones,  are  formed  from 
the  deposition  of  phosphate  of  lime  and  mucus  upon 
either  a  foieign  body  or  hardened  secretion.  They 
give  rise  to  much  swelling,  nasal  obstruction,  and  a 
foetid  discharge.  They  have  been  mistaken  for 
osteomata,  polypi,  or  even  malignant  growths.  Re- 
moval with  the  forceps,  previously  crushing  if  neces- 
sary, is  the  proper  treatment. 

Nasal  catarrh,  rhinitis,  and  coayza,  are 
terms  used  to  denote  inflammation  of  the  mucous 
membrane  of  the  nose.  The  disease  may  be  acute  or 
chronic.  As  acute  catarrh,  or  cold  in  the  head,  falls 
under  the  domain  of  the  physician  rather  than  that 
of  the  surgeon,  the  chronic  form  only  will  be  here 
described. 

Clironic  nasal  catarrh  is  most  frequently  met 
with  in  the  young,  especially  in  delicate  and  strumous 
children.  It  may  be  caused  by  oft-repeated  and  ne- 
glected attacks  of  acute  catarrh,  the  irritation  of 
noxious  dust  or  vapours,  the  abuse  of  spirits  and  snuff- 
taking,  or  the  presence  of  foreign  bodies  or  growths 
in  the  nose,  or  adenoid  vegetations  in  the  '^ault  of  the 
pharynx.  In  infants  it  may  be  due  to  congenital 
syphilis,  and  is  then  known  as  the  snuffles ;  and  in 
rare  instances  it  has  appeared  to  be  the  result  of 
gonorrhoeal  or  leucorrhoeal  infection.  Several  varie- 
ties of  the  affection  have  been  described,  all  of  which, 
however,  appear  to  be  merely  different  stages  of  the 


Nasa l  Ca  ta  rrh.  511 

same  disease.     They  will  be  here  classed  as  (1)  simple, 
(2)  hypertrojihic,  and  (3)  atroi)hic  catarrh. 

(1)  The  simple  form  is  characterised  by  a  thin 
mucous  or  muco-purulent  discharge^  and  a  con- 
gested condition  of  the  mucous  membrane,  but  there 
is  neither  thickening,  incrustation,  nor  foetor.  If 
neglected  it  may  pass  into  (2)  the  hypertrophic  form. 
In  this  stage  of  the  disease  the  mucous  membrane, 
especially  over  the  spongy  bones,  become  infilti'ated 
with  inflammatory  products,  and  appears  swollen  and 
thickened,  and  of  a  deeper  red  than  natural,  whilst 
the  glands  are  stimulated  to  extra  secretion,  and  pour 
out  a  thick  muco-purulent  discharge.  Nasal  respiration 
is  obstructed,  the  voice  is  altered  in  tone,  the  aire  nasi 
are  often  contracted  and  thickened,  and  their  mucous 
surface  covered  with  scabs.  Should  the  catarrh  spread 
to  the  naso-pharynx,  the  discharge  may  be  seen  streak- 
big  the  back  of  the  throat,  whence  it  is  continually 
being  hawked  up  in  the  form  of  pellets.  Some  gran- 
ular pharyngitis,  and  perhaps  increase  of  the  glandular 
tissue  of  the  vault,  may  co-exist,  and  possibly  deafness 
from  the  implication  of  the  Eustachian  tubes.  In 
severe  cases  the  posterior  ends  of  the  inferior  spongv 
bones  may  become  so  hypertrophied  as  to  appear  in 
the  rhinoscope  as  two  globular,  congested  tumours, 
almost  blocking  up  the  choanse.  This  condition  of  the 
mucous  membrane  is  well  seen  in  the  accompanying 
illustrations  (Figs.  105  and  106).  Occasionally  within 
a  few  months,  but  more  often  after  several  years,  the 
hypertrophic  may  pass  into  (3)  the  atrophic  variety. 
This  form,  also  called  dry  catarrh,  and  by  some,  when 
attended  with  foetor,  simple  ozcena,  is  apparently  due 
to  the  shrinking  of  the  inflammatory  new  formation 
infiltrating  the  tissues  in  the  former  variety  with  con- 
sequent atrophy  and  more  or  less  destruction  of  the 
mucous  glands.  The  nasal  cavities  appear  preter- 
naturally  large,  and  the  spongy  bones  diminished  in 


512 


Manual  of  Surgery. 


Fig.  105.— Hypertrophy  of  the  Mucotia 
Membrane  of  the  Nose,  from  a  specimen 
(No.  1762)  in  the  Museum  of  St.  Bar- 
tholomew's Hospital.  In  the  recent 
state  the  posterior  end  of  the  inferior 
spongy  bone  resembled  a  vascular  tu- 
mour. 


size,  while  the  mucous  membrane  is  pale,  dry,  and 
shrunken.  The  discharge,  which  is  viscid,  and 
secreted  in  deficient  quantity,  hardens  into  greenish- 
yellow  crusts.  The 
disease  is  generally, 
though  not  invari- 
ably, attended  with 
a  horrible  foetor,  due 
either  to  the  decom- 
position of  the  dis- 
charge beneath  the 
adherent  crusts,  or 
to  its  retention  in 
some  of  the  adjoining 
cavities  into  which 
the  catarrh  has 
spread.  When  foetor 
is  present,  as  it  oc- 
casionally is  during 
what  appears  to  be  the  hypertrophic  stage,  it  is 
probable  that  atrophy  has  already  set  in  in  some  of 
the  deeper  recesses.  It 
should  be  remembered  that 
all  three  forms  of  chronic 
catarrh  are  unattended  with 
ulceration. 

Treatment. — Except  as 
the  result  of  congenital 
syphilis  or  gonorrhceal  in- 
fection and  in  the  earlier 
stages,  chronic  nasal  ca- 
tarrh is  a  most  intractable 
malady;  indeed,  when  it 
assumes  the  atrophic  form 
little  except  amelioration  of  the  distressing  symptom 
of  fcctor  must  be  expected.  In  all  forms  the  treat- 
ment should  be  constitutional  and  local.     In  strumous 


Fig.  106.— Appearances  presented 
by  the  above  on  rhinoscopic 
examination.    (After  Leff erts. ) 


A^ASAL  Catarrh.  513 

subjects  cod-liver  oil  and  the  syrup  of   the  iodide  and 

phosphate  of  iron  should    be  persevered  in   for  long 

periods.      In    congenital  syphilis  small   doses  of  grey 

powder    or  mercurial  inunctions  generally  act  like  a 

charm.      Locally,  in  the  simple  variety  and  in  milder 

cases   of  the   hypertrophic,   the  parts  should  first  be 

cleansed,  either  by  simply  Ijlowing  the  nose  or  by  the 

use  of  some  such  lotion  as  that  known  as  Dobell's  (acid. 

carbol.   gr.   j  ;   sodii  bicarb.,   sodii  biborat.   aa  gr.  ij  ; 

glycerine  5J  ;    aquam    ad    Jj). 

Lotions  should  not  be  applied, 

as  is    too  frequently  done,   by 

means  of  the  nasal  douche,  as 

in  this  way  the  deeper  recesses 

and  upper  portions  of  the  nasal 

fossse  cannot  be  reached,  and  if 

care  is  not  taken  inflammation 

of  the  middle  ear  may  be  set 

up.      They  are  better  employed 

in  the  form  of  a  coarse  spray,     I'ig-   i'"^"-  —  Nasal    Spray 

!Pro*iiiCGr       A   x>ozz1g  tor 
either    by  the    anterior    or    ])0S-  anterior  xinres  ;   b,  uozzle 

terior  nasal  spray  producer  (Fig.        J.^;il^.rSSogue.T-   ^^' 
107)    worked    by    the    double 

hand  balls.  When  the  parts  are  thoroughly  cleansed,  as- 
tringents such  as  the  sulpho-carbolate  or  iodide  of  zinc, 
iodoform,  tannic  acid,  or  nitrate  of  silver  may  be  used 
in  the  form  of  sprays,  powders,  or  gelatine  bougies. 
Where  there  is  great  hypertrophy,  the  thickened  tissue 
should  be  destroyed  by  nitric  or  glacial  acetic  acid,  or 
by  the  galvanic  cautery.  In  using  the  cautery, 
Shurley's  sjjeculum  (Fig.  10^)  will  be  found  useful  for 
protecting  the  septum.  When  the  posterior  ends  of 
the  inferior  spongy  bones  are  much  enlarged  they  may 
sometimes  be  advantageously  removed  by  Jarvis' 
snare,  or  by  tlie  galvanic  ecraseur.  A  deflected 
septum  should  be  straightened,  and  adenoid  growths 
in  the  vault  ot  the  pharynx  should  be  extirpated. 
H   H— 21 


5H 


Manual  of  Surgery. 


Where  the  catarrli  falls  chiefly  on  the  naso-pharynx 
{retro-nasal  catarrh),  the  local  remedies  should  be 
applied  from  behind  the  palate,  by  substituting  the 
posterior  for  the  anterior  nozzle  in  the  various  spray 
producers,  etc.,  whilst  cubebs,  which  appear  to  exert 
a  special  action  on  the  glands  of  the  naso-pharynx, 
should  be  given  internally.  In  the  atrophic  form 
little  can  be  done  beyond  cleansing  and  disinfecting  the 
nasal  chambers  by  means  of  lotions  of  carbolic  or 
boracic  acid,  or  Condy's  fluid,  and  the  like.  Stimu- 
lation of  the  mucous  membrane  by  the  local  insuflSation 

of  the  sanguinaria  galanga, 
as  recommended  by  Ilobin- 
son,  and  the  continued  use  of 
Gottstein's  nasal  tampons, 
with  cubebs  internally,  may 
Fig.  308.-shnriey's    Nasal     prove  of  temporary  benefit. 

Speciilum,     for     protecting  OzaPllSl    (to    Stink)    IS     a 

S'Ia^SIcSoS     term   which   has   been   used 

very  loosely  by  authors.  By 
some  it  is  applied  to  all  diseases  of  the  nose  attended 
by  a  foetid  discharge,  whilst  by  others  it  has  been 
restricted  to  the  fcetid  form  of  atrophic  catarrh.  It  is 
better,  therefore,  to  regard  it  as  a  symptom  and  not  as 
a  disease  j)er  se.  It  is  generally  present  in  the  follow- 
ing affections  :  (1)  Atrophic  nasal  catarrh;  (2)  syphi- 
litic, lupoid,  and  tuberculous  ulceration  ;  (3)  caries  and 
necrosis  ;  (4)  some  forms  of  new  growths  in  the  nose 
and  naso-pharynx  ;  (5)  certain  diseases  of  the  antrum 
and  other  air  sinuses ;  and  (6)  foreign  bodies  and 
rhinoliths. 

Ulceration  in  the  nasal  cavities  is  generally  of  a 
syphilitic,  more  rarely  of  a  lupoid,  and  very  rarely  of 
a  tuberculous  nature.  Syphilitic  ulceration  usually 
occurs  in  the  later  stages  of  syphilis,  and  is  due  to 
the  breaking  down  of  gummata  in  the  mucous  mem- 
brane or  beneath  the  periosteum.    It  frequenth  leads 


N'asal  Caries.  515 

to  necrosis  and  caries  of  the  bones  and  cartilages,  per- 
foration of  the  septum  and  sinking  in  of  the  nose. 
Lupoid  ulceration  is  preceded,  as  elsewhere,  by  lupoid 
tubercles ;  it  is  most  common  on  the  anterior  and 
lower  part  of  the  septum,  and  just  within  the  alae  of 
the  nose,  and  not  infrequently  leads  to  a  small  perfor- 
ation. Both  forms  are  attended  with  a  muco-purulent 
and  foetid  discharge. 

Treatment.  —  In  the  syphilitic  form  iodide  of 
potassium  in  full  doses  should  be  given,  the  parts 
cleansed  with  antiseptic  sprays,  and  dead  bone,  if  de- 
tected, removed  when  loose.  In  lupoid  ulceration  the 
surface  should  be  scraped  with  a  Yolkmann's  spoon  or 
destroyed  with  caustic  or  the  galvano-cautery,  and 
cod-liver  oil  and  arsenic  should  be  given  internally. 

Caries  or  necrosis  of  the  cartilages  or  bones 
forming  the  nasal  cavities  is  generally  the  result  of 
syphilis,  but  it  may  be  due  to  struma,  lupus,  or  rodent 
ulcer,  or  may  follow  an  injury  or  long  impaction  of  a 
foreign  body.  The  bone  disease  may  be  secondary  to 
ulceration  of  the  mucous  membrane  or  to  the  breaking 
down  of  gummous  material  in  j^eriostitis  or  perichon- 
dritis. The  septum  and  the  spongy  bones  are  the  most 
frequently  affected,  but  caries  of  the  roof  of  the  nose  is 
not  infrequent.  When  the  septum  is  extensively 
involved  the  bridge  of  the  nose  may  fall  in ;  but  it  is  re- 
markable how  much  of  it  may  be  lost  in  adults  without 
any  marked  external  deformity.  A  foetid  discharge,  foul- 
smelling  breath,  depression  of  the  bridge  of  the  nose, 
a  history,  perhaps,  of  a  former  injury  or  of  dead  bone 
having  come  away,  and  concomitant  signs  of  syphilis 
or  struma,  such  as  perforation  of  the  palate  and  loss 
of  the  uvula,  are  suspicious  of  diseased  bone,  but  the 
diagnosis  can  only  be  made  certain  by  striking  it  with 
a  probe.  Though  usually  in  this  way  readily  detected, 
a  prolonged  search  with  the  patient  under  chloroform 
may  be  required,  and  Rouge's  operation  has  had  to  be 


5i6  Manual  of  Sc/kgerf. 

resorted  to  before  it  could  be  found.  If  the  surgeon 
has  a  small  index  finger  this  may  be  easily  passed 
through  the  nostril^  and  with  the  finger  of  the  other 
hand  behind  the  palate  a  very  thorough  exploration 
can  be  made. 

Treatment.  —  The  dead  bone,  as  soon  as  loose, 
should  be  removed,  the  parts  in  the  meantime  being 
kept  as  sweet  and  clean  as  possible  by  antiseptic 
sprays.  Removal  can  usually  be  readily  effected 
through  the  nostril,  but  where  this  is  not  possible 
Rouge's  operation  may  be  done. 

Tumours  or  ue^v  g^i'owths  in  the  nasafl 
cavities  are  usually  spoken  of  as  polypi,  of  which 
three  forms  are  generally  described  :  the  gelatinous, 
the  fibrous,  and  the  malignant. 

Oelatiuous  or  mucous  polypi  are  by  far  the 
most  common.  They  occur  as  soft,  gelatinous,  semitrans- 
lucent  bodies  of  a  pale  yellow  or  pinkish  colour,  and 
of  a  globular,  pyriform,  or  ovoid  shape,  but  appearing 
opaque  and  shrunken  when  preserved  in  spirit.  They 
maybe  pedunculated  or  sessile,  and  are  generally  mul- 
tiple, one  or  two  being  frequently  larger  than  the  rest. 
They  grow  from  the  mucous  membrane,  and  have  the  mi- 
nute structure  of  the  myxomata,and  are  usually  covered 
with  ciliated  epithelium.  It  has  generally  been  taught 
that  they  most  frequently  arise  from  the  superior 
and  middle  turbinated  bones,  but,  from  the  recent 
observations  of  Zuckerkaudl,  it  is  probable  that  they 
generally  have  a  deeper  origin  in  some  of  the  remote 
recesses  of  the  nose  and  neighbouring  cavities.  Rarely 
they  spring  from  the  roof,  and  very  exceptionally  from 
the  septum.  They  have  been  attributed  to  neglected 
chronic  catarrh,  and  by  Dr.  Woakes  are  believed 
to  depend  upon  a  chronic  inflammatory  condition  of 
the  muco-periosteum  lining  the  turbinated  bones  and 
tells  of  the  ethmoid,  attended  by  necrosis  of  the  osseous 
crabeculae ;  but  their  etiology  is  at  the  best  obscure. 


Nasal  Polypi.  517 

Symptoms. — The  chief  of  these  are  a  feeling  of 
obstruction  in  the  nose,  increased  in  damp  weather 
from  swelling  of  the  polypus,  and  in  some  cases 
amounting  to  complete  occlusion,  the  so-called  nasal 
tone  of  voice,  and  a  mucous,  but  not,  as  a  rule,  offen- 
sive, discharge.  Amongst  other  symptoms  that  may 
be  met  with  may  be  mentioned  frontal  headache,  deaf- 
ness, and  loss  of  smell ;  whilst  recently  certain  forms 
of  cough,  asthma,  and  epilepsy  have  been  attributed 
to  reflex  irritation  set  up  by  the  presence  of  polypi 

Diagnosis. — On  looking  into  the  nostril  they  can 
generally  be  seen,  and  may  be  distinguished  from 
hypertrophy  of  the  mucous  membrane  over  the  spongy 
bones,  for  which  they  are  most  likely  to  be  mistaken, 
by  the  characters  already  enumerated,  and  by  the 
light  or  dark  red  appearance  of  the  latter.  But  when 
high  up  or  far  back  the  speculum  or  rhinoscope  may 
be  necessary  to  detect  them. 

Treatment. — They  can  generally  be  removed 
by  the  polypus  forceps ;  but  the  use  of  the  galvano- 
cautery  is  preferable,  as  with  this  there  is  less  pain 
and  little  or  no  haemorrhage  ;  pain,  moreover,  may 
be  prevented  by  the  application  of  cocaine.  ^Yhen 
the  polypus  projects  in  the  naso-pharynx,  it  can  be 
removed  from  behind  the  palate  either  with  the 
forceps  or  with  the  galvano-cautery.  Tannic  acid 
used  as  snuff  is  said  to  prevent  a  recurrence,  but  the 
author  has  not  found  it  of  much  service. 

Fibrous  pol>'pi  rarely  arise  from  the  interior  of 
the  nose.  They  more  frequently  originate  in  the  naso- 
pharynx from  the  basilar  process  of  the  occipital  or  body 
of  the  sphenoid,  or  in  the  cavity  of  the  antrum,  and 
only  secondarily  invade  the  nose  as  they  grow  larger. 
When  arising  in  either  of  the  first  two  situations 
they  are  generally  designated  tiaso-pharyngeal  polypi. 
They  spring  from  the  periosteum,  and  consist  chiefly 
of  fibrous  tissue,  in  which  spindle-shaped  cells  are  not 


5t8  Manual  of  Surgery. 

infrequently  found.  They  are  covered  by  a  very 
vascular  mucous  membrane,  and  contain  numerous 
large  thin-walled  blood-vessels,  which  give  to  them  in 
places  almost  a  cavernous  structure.  At  first  gene- 
rally broadly  pedunculated  and  confined  to  one  side 
of  the  naso-pharynx,  as  they  increase  in  size  they 
assume  a  very  irregular  shape,  invading  the  nasal  cavi- 
ties and  the  rest  of  the  naso-pharynx,  perhaps  push- 
ing forward  or  projecting  below  the  palate,  or 
penetrating  into  the  orbit  or  spheno-maxillary  fossa, 
or  even  protruding  externally  through  the  cheek  or 
into  the  interior  of  the  cranium. 

Syni'pto'ms. — At  first  these  may  be  slight,  but 
sooner  or  later  there  will  be  obstruction  of  one  or 
both  nostrils,  attended  by  a  mucous  and  often  foul- 
smelling  discharge,  repeated  attacks  of  haemorrhage, 
and  perhaps  deafness  or  trouble  in  breathing  and 
swallowing ;  whilst  later,  as  the  bones  are  invaded 
and  displaced,  the  face  assumes  the  characteristic 
appearance  known  as  "frog-face."  They  are  most 
common  in  young  adult  life,  and,  if  not  removed,  may 
produce  fatal  exhaustion  from  the  repeated  haemor- 
rhages, though  in  some  instances  they  have  undergone 
atrophy  as  the  patient  grew  older.  They  may  be 
known  by  their  firmness,  smoothness,  dark  red  colour, 
and  proneness  to  bleed  on  examination. 

The  diagnosis  is  readily  effected  by  the  aid  of  the 
rhinoscope  or  the  finger  passed  behind  the  soft  palate, 
while  at  times  they  may  be  seen  with  or  without  the 
speculum  on  looking  into  the  nostril. 

Treatment. — Kemoval  by  the  galvano-cautery,  the 
wire  being  passed  through  the  nares  and  directed  over 
the  base  of  the  growth  by  the  finger  behind  the  soft 
palate,  the  base  being  afterwards  destroyed  by  Lincoln's 
electrode,  is,  perhaps,  the  best  treatment  when  the  poly- 
pus is  of  moderate  size.  If  too  large  to  admit  of  this, 
an  attempt  may  be  made  to  reduce  it  within  removable 


Nasal  Polypi.  519 

limits  by  electrolysis  ;  or,  this  not  being  considered 
advisable,  an  exposure  of  the  growth  must  first  be 
obtained  in  one  of  the  following  ways,  and  its  re- 
moval then  accomplished  either  by  the  galvano- 
cautery  or  ecraseur.  If  chiefly  confined  to  the  naso- 
pharynx, exposure  is  best  obtained  by  splitting  the  soft 
palate,  and  if  more  room  is  still  required,  by  chiselling 
away  part  of  the  hard  palate  as  well  (Nelaton's 
method)  ;  or,  when  chiefly  invading  the  nasal  cavities, 
by  turning  back  the  ala  of  the  nose  after  splitting 
the  upper  lip  in  the  middle  line,  or  even  removing 
the  superior  maxillary  bone.  Rouge's  operation  of 
turning  up  the  upper  lip  and  cartihiginous  portion  of 
the  nose,  and  Langenbeck's  method  of  resecting  the 
maxillary  bone,  have  each  their  advocates,  but  I 
have  not  found  exposure  by  the  former  so  good 
as  that  by  turning  back  the  ala  after  splitting  the 
lip,  and  the  resection  of  the  maxillary  bone  is  cer- 
tainly attended  with  greater  risks  than  its  mere 
removal. 

Maligrnaiit  polypi  may  have  either  a  sarcomatous 
or  carcinomatous  structure,  and  may  arise  in  the  nasal 
cavities,  naso-pharynx,  or  antrum.  The  symptoms 
attending  them  are  similar  to  those  of  the  fibrous 
variety  already  described ;  but  they  grow  more 
quickly,  infiltrate  as  well  as  invade  surrounding  parts, 
and  sooner  or  later  involve  neio^hbourinor  irlands.  A 
microscopical  examination  of  a  small  portion  will 
reveal  its  exact  structure.  Early  and  complete 
removal,  when  there  is  a  fair  prospect  of  being  able  to 
get  away  the  whole  gro"S7th,  is  the  treatment  that 
should  generally  be  adopted. 

Adenoid  vcg:ctatioii8  consist  of  sessile,  pedun- 
culated, or  fringe-like  growths,  due  to  hypertrophy  of 
the  adenoid  tissue,  so  abundant  in  the  vault  of  the 
pharynx  and  in  the  region  of  the  choanse.  They  are 
most  common  in  childhood,  and  are  of  more  fi*equent 


520  Manual  of  Surgery. 

occurrence  in  northern  Europe  than  in  this  country. 
They  have  been  attributed  to  cold  and  damp,  the  exan- 
themata, etc.,  but  their  etiology  is  obscure.  Symptoms. 
— Obstructed  breathing  in  infants,  and  in  older  children 
deafness,  are  usually  the  symptoms  that  first  attract 
attention.  The  voice  has  a  peculiar  tone,  described  by 
Meyer  as  of  a  "dead"  character.  The  countenance  has 
a  vacant  expression  from  the  breathing,  in  consequence 
of  the  nasal  obstruction,  being  carried  on  through  the 
half-open  mouth,  whilst  nasal  catarrh,  granular  pharyn- 
gitis, enlargement  of  the  tonsils,  and  purulent  otitis,  are 
not  infrequently  present. 

The  diagnosis  can  be  readily  made  by  passing  the 
finger  behind  the  palate,  and  by  the  aid  of  the  rhino- 
scope.  To  the  finger  they  feel  soft,  yielding,  irregular, 
pulpy,  and  velvety,  like  a  bag  of  earthworms  as  Meyer 
puts  it ;  whilst  in  the  mirror  they  appear  as  irregular, 
pink  or  reddish,  sessile  or  pedunculated,  fringe-like 
masses,  partially  obscuring  the  posterior  nares. 
Bleeding  commonly  attends  the  examination. 

Treatment. — Though  they  have  a  tendency  to 
atrophy  as  the  patient  gets  older,  removal  is 
generally  called  for,  as  they  may  lead  to  permanent 
deafness.  This  in  slight  cases  may  be  effected  by  the 
application  of  solid  nitrate  of  silver  or  astringent 
solutions.  The  softer  varieties  may  be  scraped  oflf 
with  the  finger  nail,  whilst  the  larger  and  firmer  may 
perhaps  best  be  removed  by  Loewenberg's  forceps, 
guided  by  the  mirror  or  finger.  Those  near  the 
Eustachian  tube  require  careful  management  lest  the 
tube  be  injured,  and  may  most  conveniently  be 
destroyed  by  Meyer's  ring  knife,  which  is  passed 
through  the  nose,  or  by  a  small  galvano-cautery  guided 
by  the  mirror  with  the  patient  under  chloroform  and 
the  soft  palate  tied  up. 

€oiig:eiiital  deformities  of  the  nose  are  rare 
and  of  little  surgical  interest.     Tbe  only  one  to  which 


Lipoma  Nasi.  521 

reference  need  be  made  here  is  occlusion  of  the 
nostrils.  An  incision,  where  this  is  merely  mem- 
branous, will  generally  suffice,  but  in  some  cases  a 
plastic  operation  will  be  necessary. 

Diseases  of  the  exterior  of  the  nose. — The 
affections  to  which  the  external  parts  of  the  nose  are 
most  liable  are  :  lupus,  rodent  ulcer,  epithelioma,  acne 
rosacea,  and  lipoma  nasi  These,  with  the  exception 
of  the  last  named,  present,  when  attacking  the  nose, 
■»  no  special  features,  and  the  reader  is  referred  for  a 
description  of  them  to  Arts.  v.  and  xxiv.,vol.  i. 

Lipoma  nasi  is  a  hypertrophy  of  the  sebaceous 
follicles  and  surrounding  skin  and  subcutaneous  tissue, 
not,  as  the  name  seems  to  imply,  of  the  fatty  tissue. 
It  has  been  ascribed  to  exposure  and  alcoholism,  and 
is  most  common  after  middle  age.  The  tip  and  alse 
of  the  nose  are  chiefly  affected,  being  transformed  into 
irregular,  lobulated,  prominent,  or  pendulous  masses, 
on  which  the  apertures  of  the  hypertrophied  glands  are 
seen  as  pit-like  depressions.  Occasionally  pale,  they 
are  perhaps  more  often  of  a  purplish-red  colour,  and 
traversed  by  dilated  capillaries. 

Treatment. — The  masses  should  be  shaved  off  with 
a  sharp  scalpel,  care  being  taken  not  to  penetrate  the 
cartilages.  The  improvement,  when  the  parts  have 
cicatrised,  is  veiy  marked. 

Atfections  of  the  septum.  — Blood  tumours  are 
occasionally  met  with  as  the  result  of  fracture  of  the 
sej)tum  or  other  injury.  The  blood  is  extra vasated 
between  the  cartilage  and  the  soft  tissues,  causing  a 
circumscribed,  fluctuating  swelling,  of t€n  on  both  sides 
of  the  septum,  which  may  readily  be  distinguished 
from  abscess  by  its  appearing  immediately  after  the 
injury  and  by  the  absence  of  inflammation.  The 
blood,  as  a  rule,  is  slowly  absorbed,  but  may  break 
down  into  pus.  In  the  latter  circumstance  only  should 
an  incision  be  made  into  the  swelling. 


522  AfANUAL    OF   SUKGERV. 

Abscess  may  occur  after  an  injury,  breaking  down 
of  a  blood  tumour  or  gumma,  and  sometimes  without 
any  evident  cause.  The  signs  of  inflammation  and 
fluctuation  serve  to  distinguish  abscesses  from  other 
tumours.     They  should  be  opened  early. 

Cartilaginous  and  osseous  tumours  forming  out- 
growths from  the  septum  and  projecting  into  the 
nostril  are  sometimes  met  with.  The  absence  of  a 
depression  on  the  opposite  side  distinguishes  them 
from  deviation  of  the  septum.  They  may  be  removed 
either  by  the  knife,  saw,  or  dental  engine. 

Deviatio7i    of  the    septum   to    one    or   other   side 

may  occur  as  the  result  of 
a  blow  or  fall  upon  the 
nose,  or   as  a  congenital 

''''■dXMenS'rs!^IZ:'"V^l     malformation.    It  appears 
noid's  Catalogue.)  as   a  swelling  projecting 

into  and  more  or  less  ob- 
structing one  of  the  nasal  cavities,  and  may  readily  be 
distinguished  from  a  polypus,  for  which  it  has  some- 
times been  mistaken,  by  the  presence  of  a  correspond- 
ing depression  on  the  opposite  side.  It  is  generally 
attended  with  some  lateral  deviation,  and  perhaps 
depression  in  the  case  of  injury  of  the  lateral  cartilages 
or  even  of  the  nasal  bones.  The  inferior  turbinated 
body  on  the  side  corresponding  to  the  concavity  is 
often  much  hypertrophied.  The  symptoms  commonly 
complained  of  are  obstructed  nasal  respiration,  altered 
tone  of  voice,  and  a  continual  chronic  catarrh  ;  whilst 
sometimes  frontal  headache,  giddiness,  and  certain 
other  distressing  symptoms  referable  to  nasal  obstruc- 
tion are  present. 

Treatment. — The  septum  may  generally  be  forcibly 
straightened.  I  have  found  the  forceps  shown  in  the 
woodcut,  which  are  a  modification  of  Adams',  best 
for  the  purpose,  the  large  bows  below  the  blades 
protecting  tlie  columnella.     The  straightened  septum 


Deviations  of  Nasal  Septum. 


523 


should  then  be  kept  in  position  l)y  retentive  apparatus  ; 
the  hollow  plugs  made  for  me  by  Messrs.  Arnold  will 
be  found  useful  for  this  purpose. 
In  some  cases  portions  of  the 
prominent  septum  may  be  advan- 
tageously excised.  Deviated  carti- 
lages should  be  rectified  at  the 
same  time,  and  even  where  the 
bones   have    been    displaced    they 


may    be    straightened    even    after 


Fij?.  110.— Walsliam's 
Mask  for  making 
Pressure  on  crooked 
Nose.  (Arnold's 

Catalogue. ) 


many  years.     Great  force,  however, 

is  often  necessary,  and  the  forceps 

must  be  carefully  padded  to  prevent 

injury  to  the  soft  parts.      In  these 

severe    cases    I    have    found    the 

Fig.  110  of  service,  as  in  its  use  a  fixed  point  is  gained 

to  bear  on  the  displaced  parts. 


mask    shown    in 


524 


XIII.     DISEASES   OF  THE   EAR. 

George  P.  Field. 

Specific  Aiiictions  of  the  auditory  ap- 
paratus.— The  perception  of  sound  is  commonly 
due  to  motion  of  the  chain  of  ossicles  connecting  the 
tympanic  membrane  with  the  internal  ear,  the  intra- 
labyrinthine  fluid  of  which,  being  set  in  vibration, 
occasions  disturbance  of  the  processes  of  the  organ  of 


IrLCus 


StapGSv 


Mailleiis 


Malleus 


TlLCUS 


\ Stapes 


Fig.  111.— The  Auditory  Ossicles  Fig.  112.-  -The  Auditory  Ossicles 

viewed  from  within  the  Tyin-  viewed  from  within  the   Ex- 

pauum (enlarged).  ternal  Meatus  (enlarged). 

The  dotted  line  indicates  the  position  of  the  drum-head. 


Corti  and  of  the  cochlear  and  ampullar  air  cells,  with 
concussion  of  the  otoliths  contained  in  the  endolymph 
of  the  utricle  and  saccule.  The  differentiation  of 
sonorous  impulses  is  presumably  rendered  possible  by 
their  passage  through  the  whole  length  of  the  peri- 
lymph to  affect  the  endolymph.  Sounds  not  con- 
veyed by  the  ossicles  may  travel  to  the  membrane  of 
the  fenestra  rotunda  across  the  middle  ear,  or  more 
directly,  and  seemingly  to  the  cochlea  and  ampullae, 
through  the  bony  labyrinth  or  the  skull. 

Of  the  ossicles,  the  stapes  is  that  most  essential, 
serving,  in  common  with  the  membrane  of  the  fenestra 


Examination  of  the  Ear.  525 

ovalis,  to  (lam  back  the  fluid  of  the  internal  ear.  Of 
the  labyrinth,  biology  indicates  the  vestibule  to  be 
fundamentally  the  most  important  part.  Intensity 
of  sound  appears  to  be  interpreted  by  the  vestibular 
nerve,  and  difference  in  tone  by  the  organ  of  Corti, 
Cyon's  view,  that  the  semicircular  canals  are  the  peri- 
pheral organs  of  the  sense  of  space,  seems  probable. 

The    Eustachian    tube    serves    (1)    to    maintain 
equality  of  atmospheric    pressure    on    the    tympanic 


Fig.  113.— Brunton's  Otoscope  in  use. 

membrane;  (2)'  to  drain  off  excess  of  mucus;  and 
(3)  to  prevent  echo  by  affording  passage  for  son- 
orous undulations  from  the  middle  ear.  The  inner 
end  is  generally  considered  to  be  opened  only  at  the 
conclusion  of  deglutition. 

Examiuatioii  and  treatment  of  patients. 
— In  children,  the  external  auditory  canal,  it  must  be 
remembered,  differs  from  that  of  adults  in  being  less 
in  its  vertical  than  in  its  horizontal  diameter.  Of 
otoscopes,  Brunton's  is  that  most  universally  service- 
able (Fig.  113) ;  but  usually  a  concave  mirror,  with  a 
forehead  strap  for  use  if  required,  and  an  ordinary 
silver  ear  speculum,  sujfice. 


526  Manual  of  Surgery, 

A  liealthy  drum-liead  appears  of  a  delicate  blue- 
grey  colour,  and  through  it  is  seen  the  handle  of  the 
malleus  running  downwards  and  backwards,  with  the 
apex  of  the  white  spot  at  its  extremity. 

To  test  a  patients  hearing  power,  bring  the 
watch  or  other  sound-producer  gradually  to  the  ears, 
and  make  a  note  of  the  distance  at  which  it  is  first 
audible.  Conversational  tests  must  be  applied  so  as 
to  preclude  lip-reading.  It  should  be  borne  in  mind 
that  the  relative  audibility  of  different  sounds  may 
vary  with  the  patient's  condition.  The  tuning  fork 
applied  to  the  forehead  distinguishes  betwixt  mere 
obstruction  to  the  passage  of  sound  reaching  the 
meatus  and  defect  in  the  auditory  nerve  {i.e.  betwixt 
impairment  of  the  sound-conducting  and  the  sound- 
perceiving  capacity  of  the  ear),  its  vibrations  in  the 
former  case  being  by  reverberation  considerably  in- 
tensified, although  the  ear  may  be  totally  insensitive 
to  aerial  sound  waves.  Diminished  audibility  of  bone- 
conducted  sounds  may  be  due  to  (1)  senile  changes  in 
the  auditory  nerve,  or  (2)  to  acute  otitis. 

Whispering,  in  which  diminution  in  the  vowel 
sounds  renders  the  consonants  the  more  easily  dis- 
tinguishable, is  usually  better  heard  by  the  deaf  than 
ordinary  speech.  Increase  in  the  apparent  perception 
of  high  musical  tones  is  said  to  indicate  greater  though 
limited  tension  of  the  drum-head,  or  breach  of  its 
substance,  admitting  the  easy  passage  of  short  sound 
waves  to  the  labyrinth.  The  audiV)ility  of  high  sounds 
is  best  arrived  at  with  the  aid  of  Konig's  rods,  or 
Galton's  whistle.  Paracentesis  Willisii,  or  improvement 
in  the  hearing  of  some  deaf  persons  during  noise,  is 
compatible  with  very  different  conditions  of  the  drum, 
and  may  be  due  to  an  exaltation  by  the  noise  of  the 
impaired  functions  of  the  auditory  nerve,  without  the 
creation  of  corresponding  auditory  impulses.  Another 
and   perhajjs   more   probable   explanation  is,  that  the 


Diseases  of  External  Meatus.         527 

improvement  in  a  noise  is  consequent  on  the  extra 
shaking  of  ossicles  which  have  become  fixed  from  some 
catarrhal  inflammation. 

Diseases  of  the  external  meatus  of  the 
car. — Impacted  wax  in  the  ear  can  usually  be  re- 
moved bj  gentle  syringing  with  water  at  100°  F.  ; 
in  some  instances  it  should  be  previously  softened  by 
the  installation  of  warm  solution  of  bicarbonate  of 
soda  (gr.  x  ad  Jj),  which  is  especially  useful  in  exam- 
ples of  keratosis  obturans  (over-accumulation  in  the 
meatus  of  epithelial  laminae). 

Abnormal  dryness  of  the  external  meatus  may  be 
indicatory  of  disease  of  the  internal  ear.  Fluidity 
and  offensiveness  of  cerumen  in  children,  if  not  cor- 
rected, are  apt  to  lead  to  catarrhal  inflammation  or 
worse  results. 

With  patients  complaining  oi  foreign  bodies  in  the 
meatus,  it  is  well  to  ascertain,  by  means  of  the  specu- 
lum, that  there  is  actually  anything  foreign  to  be 
removed.  Avoid,  where  possible,  instrumental  inter- 
ference, to  which  complete  inaction  may  be  preferable. 
Careful  syringing  along  the  roof  of  the  meatus,  the 
auricle  being  drawn  upwards  and  backwards,  is 
generally  all  that  is  required,  the  patient,  if  necessary, 
being  placed  on  his  side  or  back.  But  this  treatment 
should  not  be  adopted  if  the  foreign  body  has  occa- 
sioned much  swelling  of  the  soft  parts  ;  in  this  case 
the  inflammation  should  be  relieved  by  leeching  freely 
in  front  of  the  tragus.  The  offending  substance  may 
sometimes  be  removed  by  affixing  it  with  glue  or 
coaguline  to  a  piece  of  linen  or  a  brush,  or  by  the 
use  of  adhesive  plaister  on  a  string.  If  it  is  swollen 
by  absorption  of  moisture,  the  use  of  glycerin  may  be 
effectual.  In  some  cases  an  anaesthetic  is  necessary. 
Epileptiform  convulsions  or  symptoms  like  those  of 
Meniere's  disease  sometimes  result  from  irritation 
caused  by  foreign  bodies  in  the  meatus. 


528  Manual  of  Surgery, 

For  hoih  in  the  meatus,  poultices  (not  admissible 
in  other  instances  of  aural  inflammation),  glycerine 
applications  to  relieve  pain,  and  lancing  and  subse- 
quent treatment  with  boracic  acid,  should  be  resorted 
to.  Defective  house-drainage  is  said  to  be  the  cause 
of  abscesses  in  the  ear. 

Insects  or  their  larvae  in  the  auditory  canal  can 
be  destroyed  by  warm  oil  or  chloroform  vapour,  and 
then  removed  by  syringe  or  forceps. 

Aspergillus,  the  fungus  most  usually  met  with  in 
the  ear,  follows  on  eczema  or  other  inflammation 
aflfecting  the  epidermis.  Its  growth  is  fostered  by  a 
damp,  ill-ventilated  atmosphere.  With  the  symptoms 
characteristic  of  inspissated  cerumen,  it  causes  dull 
pain.  It  is  best  combated  by  frequent  applications  of 
solution  of  lead  acetate,  chlorinated  lime,  or  of  potas- 
sium permanganate,  or  by  chlorine,  bromine,  and 
iodine  water,  or  applications  of  alcoholic  2  to  4  per 
cent,  solution  of  salicylic  acid. 

Narrowing  of  tlie  meatus  from  chronic  inflamma- 
tion indicates  recourse  to  constitutional  remedies,  and 
locally  the  application  of  strong  solution  of  silver 
nitrate,  or  of  ointment  of  ung.  hydrarg.  nit,  and  ung. 
zinci  (1  to  8).  The  insertion  of  a  series  of  lubricated 
short  imperforate  drainage  tubes  may  at  times  be  use- 
ful. Erysipelas,  molluscous  or  sebaceous  tumours, 
and  various  other  causes  of  stenosis  must,  of  necessity, 
receive  specific  treatment. 

Otorrhagia  (bleeding  from  the  external  auditory 
meatus)  usually  results  from  polypus,  or  it  may  be 
due  to  injury  to  the  base  of  the  skull  or  to  the  internal 
carotids,  the  membrana  tympani,  or  the  walls  of  the 
meatus.  It  may  occur  also  in  purpura,  yellow  fever, 
and  malignant  small-pox,  in  acute  aural  catarrh,  in 
Bright's  disease,  in  the  condition  known  as  otitis 
haemorrhagica,  and  in  suppression  of  the  menses. 

"  Ear  cough"  due   to   irritation    of    the   external 


Diseases  of  Auricle. 


529 


auditory  meatus  or  of  the  outer  layer  of  the  drum- 
head, is  regarded  as  a  reflex  result  of  aflfection  of  a 
branch  of  the  pneumogastric  su])plyiiig  the  same. 

Diminution  in  the  calibre  of  the  external  auditory 
canal  from  diffuse  thickening  of  its  bony  walls  may  be 
treated  by  the  insertion  of  small  ivory  bougies.  The 
commonest  bony  outgrowths,  or  exostoses,  in  the 
meatus  originate  usually  in  inflammation  of  the  middle 
ear,  are  of  rapid  growth,  and  mostly  pedunculated. 
Being  of  the  nature  of  spongy 
osteomata,  they  can  be  removed  by 
tlie  ecraseur.  In  minute  structure 
they  resemble  newly-formed  bone. 
The  majority  of  the  multiple  out- 
growths, which  are  commonest  in 
the  wealthy  classes,  are  more  com- 
pact, and  histologically  comparable 
with  syphilitic  nodes  on  the  cranial 
flat  bones.  True  ivory  exostoses, 
or  hyi^erostoses,  are  still  denser  in 
structure,  and  of  rarer  occurrence  ; 
are  painless,  and  usually  bilateral ; 
and  are  the  effect  neither  of  active 
inflammatory  changes  nor  of  con- 
genital tendency,  but  apparently  of  a  chronic  irritation 
of  the  meatus,  such  as  is  producible  (as  the  author 
flrst  pointed  out)  by  constant  sea-bathing.  For  their 
removal,  drilling  with  Matthewson's  dental  engine  has 
proved  the  most  effective  measure.  During  the  opera- 
tion a  steel  guard  is  needed  to  protect  neighbouring 
structures. 

Diseases  of  the  auricle  and  associated 
parts* — Malformations  may  be  due  to  defective  or 
excessive  developmental  actiWty  in  the  tissues  bound- 
ing the  first  post-oral  cleft,  in  the  minute  folds  of 
which  dermoid  cysts  in  the  external  meatus  probably 


Fig.  114,  —  Multiple 
Exostoses  bounding 
a  Triangular  Open- 
ing. 


originate. 


I  1-21 


530 


Manual  of  Surgery. 


Among  other  affections  of  the  auricle  are  warts, 
chalk  stones  in  the  upper  part  of  the  helix  in  gouty . 
persons,  epithelioma,  keloid  growths,  and  cicatrices 
caused  by  ear-ring  punctures,  traumatic  and  idiopathic 
otha^inatomata^  or  blood  tumours,  herpes,  erysipelas 
(usually  chronic),  and  syphilitic  eruptions. 

Idiopathic  othceniatomata  usually  occur  in  the 
insane,  and  are  pathognomonic  of  disease  of  the  base 
of  the  brain.  In  eczema  of  the  auricle  it  is  important 
to  ascertain  that  topical  applica- 
tions are  not  being  rendered  use- 
less by  uncured  otorrhoea.  Con- 
tagious impetigo  of  the  auricle 
requires,  first,  removal  of  scabs, 
and  then  destruction  of  pus  by 
carbolic  lotion  and  mercurial  oint- 
ment. Chilblain  is  best  treated 
by  warmth  and  spirit  liniment, 
and  pruritus  by  soothing  lotions 
and  ointments  containing  opium, 
creasote,  hydrocyanic  acid,  and 
mercurials.  Ichthyosis  of  the 
auricle  is  alleviated  by  the  con- 
tinued application  of  glycerine.  For  lupus  erythema- 
tosus treat  by  early  inunction  with  cod-liver  oil, 
followed  by  scarification  and  general  tonics, 

Syphilis,  either  secondary  or  tertiary,  has  been 
observed  to  affect  the  ear  (probably  both  the  middle 
ear  and  labyrinth),  by  bringing  on  (1)  changes  in  the 
drum-head ;  and  (2)  deafness,  which  is  usually  painless 
and  unilateral,  is  rapid  in  onset,  and  is  like  that  produced 
by  obstruction  in  the  meatus,  so  that  by  bone  conduc- 
tion a  tuning  fork  is  better  heard  in  the  affected  ear. 
Again,  syphilis  attacking  the  labyrinth  or  auditory 
nerve  may  cause  deafness,  commonly  absolute,  of  one 
or  both  ears,  the  healthy  ear  alone  being  then  sensitive 
to  bone-conducted   sound.       Syphilitic  tliroat  disease 


Fig, 


115.  —  Othaema- 
toma. 


A  UR  A  L     Ca  TARR  H. 


531 


V- 


is  a  not  uncommon  ori^rin  of  acute  aural  catarrh. 
Nervous  deafness  from  hereditary  syphilis  generally 
comes  on  between  the  ages  of  10  and  16,  together  with 
chronic  interstitial  keratitis,  and  is 
much  more  common  in  girls  than 
boys.  UndouVjtedly  the  best  treat- 
ment is  the  administration  of  grey 
powder ;  but  the  prognosis  is  un- 
favourable. 

Aural  catarrh. — Acute  aural 
catarrhal  inflammation,  usually  uni- 
lateral and  the  result  of  catching  a 
cold,  is  characterised  by  increased 
vascularity  of  the  drum-head,  and  by 
continuous  intense  pain  preceding  the 
discharge,  as  also  by  pain  on  eructa- 
tion or  forcible  expiration,  and  in 
children  notably  by  intolerance  of 
rest  of  the  head  on  the  side  aflected. 
Convulsions  are  an  occasional  compli- 
cation. Fomentation  by  instillation 
of  warm  water,  mild  purgation,  the 
careful  use  of  Politzer's  bacj  to  favour 
escape  of  pent-up  pus  from  the 
Eustachian  tube,  and  also  leeching  in 
front  of  the  tragus,  are  the  usually 
efficacious  modes  of  treatment.  Simple 
acute  non-suppurative  catarrh  rarely 
causes  perforation  of  the  drum-head.' 
It  may  originate  in  inflammation  of 
that  structure  only  (myringitis).  Foul 
air  and  also  over-doses  of  quinine 
have  both  been  known  to  produce 
aural  catarrh.  In  cases  of  chronic 
catarrh  attention  should  be  given  especially  to  the 
promotion  of  the  general  health  by  the  use  of  warm 
clothing,  by  the  administration  of  cod-liver  oil,   and 


F"g.  116.  —  Polit- 
zer's Basr,  with 
Nasal  Pad. 


532 


Ma.yual  of  Surgery 


also  by  the  application  of  astringents  to  the  throat 
and  of  iodine  over  the  mastoid  process  ;  inflation  of  the 
tympanum  with  Politzer's  bag,  or  with  simply  a  piece  of 
rub]  er  tubing  in  the  case  of  children, 
may  often  prove  of  great  value. 

Folitzerisation,  commonly  practised 
at  the  moment  of  swallowing,  may  be 
promoted  also  by  the  pronunciation  of 
certain  syllables  (as  "  buck "),  or  by 
puffing  out  the  cheeks.  The  diagnostic 
or  auscultation  tube,  one  end  of  which 
is  placed  in  the  patient's,  the  other  in 
the  surgeon's  ear,  enables  the  observer, 
by  the  sound,  gurgling  or  whistling,  at 
tlie  moment  of  politzerisation  to  ascertain 
the  existence  of  fluid  in  the  tym2:)anum 
or  of  a  perforation  in  the  drum- head. 

Excision  of  the  tonsils  and  prolonged 
treatment  of  the  naso-pharynx  may  be 
necessary  in  cases  of  deafness  from  con- 
tinued closure  of  the  Eustachian  tube, 
one  evil  result  of  which  is  to  cause  in- 
ward bulging  of  the  drum-head  from 
exhaustion  of  the  tympanic  air. 

In  aural  catarrh  unbenefited  by 
politzerisation,  the  Eustachian  catheter 
must,  except  with  children,  be  employed. 
To  those  who  are  unaccustomed  to  the 
instrument,  the  following  method  of  using 
it  will  be  found  serviceable.  It  should 
be  passed  along  the  floor  of  the  nares  to 
the  posterior  wall  of  the  pharynx,  with- 
drawn, and  turned  inwards  to  hook  round 
the  vomer,  and  then  semirotated  downwards  till  the 
point  is  directed  outwards  and  slightly  upwards,  when 
it  enters  the  mouth  of  the  Eustachian  tube.  The  intro- 
duction of  air  or  fluids  into  the  tube  is  best  effected 


Fig.  117.— The 
Eustachian 
Catheter. 


Deafness. 


533 


through  a  piece  of  indiarubber  piling  connected  with  the 
injector  or  indiarubber  bag,  which  is  suspended  from  the 
operator's  coat,  and  is  compressed  with  the  right  hand 
while  the  left  steadies  the  catheter.  Variable  hearing 
is  a  pretty  sure  sign  of  defective  action  of  the 
Its  intermittent  and   progressive 


sure 
Eustachian  tube. 


Fig.  118. — The  Eustachian  Catheter  in  position. 


dilatation  by  bougies  introduced  through  a  catheter 
has  been  successfully  practised  by  Meniere  and  others. 

In  chronic  non-suppurative  inflammation  of  the 
middle  ear,  vapours  of  ammonium  chloride  are  recom- 
mended in  a  catarrhal  and  simjjle  or  iodised  aqueous 
vapour  in  a  dry  condition  of  the  mucous  membrane ; 
but  injection  of  astringent  and  slightly  stimulating 
fluids  is  often  useful. 

Daily  massage  over  the  mastoid  region  is  recom- 
mended by  Eitelberg  for  acute  and  subacute  middle- 
ear  catarrh. 

Where   the   cause  of   deafness   is  due,  not  to 


534  Manual  of  Surgery. 

deficiency  of  atmospheric  pressure  but  to  thickening 
of  the  mucous  lining  of  the  middle  ear,  or  to  adhe- 
sions within  the  tympanum,  the  local  effect  of  solution 
of  potassium  iodide  (gr.  x  ad  ^j)  is  beneficial ;  and, 
similarly,  weak  solution  of  iodine,  copper  sulphate, 
potash,  silver  nitrate,  or  of  chloral  hydrate  may  be  very 
efficacious,  as  well  as  the  internal  administration  of 
potassium  iodide  and  mercury  perchloride,  these  last 
particularly  in  strumous  patients.  The  severance  of 
adhesions  is  sometimes  to  be  efiected  by  the  use  of  a 
pneumatic  tractor.  Bing,  of  Vienna,  states  that 
words  spoken  into  the  Eustachian  catheter  are  not 
heard  if  the  stapes  is  fixed,  fixation  of  the  malleus  and 
incus  alone  not  preventing  their  audibility. 

Adenoid  vegetations  in  the  pharynx  may  be  the 
source  of  deafness  by  closing  the  mouth  of  a  healthy 
Eustachian  tube,  or  by  so  blocking  the  nares  that  swal- 
lo\ving  occasions  rarefaction  of  the  tympanic  air. 
These  growths  may  be  removed  very  easily  with 
instruments^  or  even  with  the  finger  nail. 

Serous  effusions  in  the  tympanum  are  commonly 
absorbed  after  politzerisation.  Where  catheterisation 
does  not  avail  for  syiinging  out  the  t}Tnpanum,  punc- 
ture of  the  drum-head  may  be  of  value.  This  should 
be  efiected  in  the  lower  portion,  before  or  behind  the 
handle  of  the  malleus.  The  tympanum  can  then  be 
evacuated  by  infiation,  or  by  the  use  of  a  Siegle's 
speculum.  Paracentesis  is  required  also  when,  in 
acute  suppurative  aural  inflammation  (a  possible 
sequela  of  scarlet  fever,  typhoid,  typhus,  diphtheria, 
and  other  diseases),  pus  pent  up  in  the  tympanum 
fails  to  burst  through  the  membrana  tympani,  or  to 
escape  through  the  Eustachian  tube,  and  so  causes 
the  drum-head  to  bulge  outwards.  Spontaneous  per- 
foration is  otherwise  a  probable  event ;  but  in  some 
cases  the  accumulated  pus  rapidly  produces  fatal 
meningitis  or  cerebral  abscess. 


Otorrhcea.  535 

Otoriii€Da,  or  discharge  of  the  pus  from  the  middle 
ear,  is  not  necessarily  ushered  in  by  acute  otitis,  being 
e.g.  a  common  symptom  in  struma.  For  treatment, 
the  main  indications  are  restoration  of  the  general 
health,  thorough  cleansing  of  the  ear,  and  frequent 
syringing  with  warm  water,  and  afterwards  the  ap- 
plication of  lotions  containing  zinc  salts,  carbolic 
acid,  or  rectified  spirits.  These  various  astringents 
should  be  changed  occasionally.  Counter-irritation 
behind  the  ears,  and  the  insufflation  of  powdered  alum, 
iodoform,  or  boracic  or  salicylic  acid,  and  repeated  ap- 
plications of  boroglyceride,  may  be  very  useful.  The 
origin  of  inflammation  in  an  atmosphere  contaminated 
with  sewer  gas  must  be  guarded  against.  The  intro- 
duction into  the  tympanum  of  a  medicated  fluid  poured 
into  the  meatus  may,  when  a  very  small  perforation 
in  the  drum-head  exists,  be  simply  efiected  by  Val- 
salva's method  of  closing  the  mouth  and  nostrils,  and 
blowing,  the  bubble  of  air  then  conveyed  by  the 
Eustachian  tube  being  replaced,  as  it  passes  out 
through  the  drum-head,  by  a  drop  or  so  of  the 
fluid.  Neglected  otorrhcea  may  become  chronic,  and 
may  cause  polypus,  thickening  of  the  drum-head,  de- 
struction of  the  ossicles,  and  caries  of  the  mastoid,  or 
even  facial  paralysis,  haemorrhage  from  the  carotid 
artery,  inflammation  of  the  brain,  epilepsy,  or  by  the 
formation  of  thrombi  in  the  lateral  sinus  or  the  jugu- 
lar, pysemic  lobular  pneumonia. 

Ali'ectioiis  of  the  membrana  tynipani. — 
Traumatic  slits  or  cuts  in  the  membrana  as  a  rule 
heal  readily,  and  the  tendency  in  cases  of  direct  injury 
generally  is  towards  recovery.  Perforations  from 
disease,  however,  are  apt  to  become  permanent,  if 
otorrhcea  be  not  arrested,  and  the  health  of  the  middle 
ear  restored.  A  perforation  is  not  incompatible  with 
fair  audition,  its  position  and  the  state  of  the  ossicles 
having  considerable  influence.      Deafness  owing  to  a 


536  Manual  of  Surgery. 

perforation  or  to  separation  of  the  ossicles  is  some- 
times greatly  benetited  by  the  pressure  or  support 
afforded  by  an  artificial  membrane  or  a  plug  of  cotton 
wool,  which  may  be  suitably  combined.  Dr.  0.  W. 
Tangeman  has  recorded  a  case  of  double  perforation 
successfully  treated  by  skin  grafting.  Mammilliform 
perforations  may  be  effectually  treated  by  instillation 
of  rectified  spirit,  as  shown  by  Professor  Zaufal. 

Disease  of  tlie  mastoid  process  is  character- 
ised by  deep-seated  local  pain  and  signs  of  inflamraa* 
tion.  Early  and  thorough  incision  over  it  down  to  the 
bone,  followed  by  free  leeching,  repeated  washing  with 
antiseptic  and  astringent  lotions,  and  treatment  of  the 
general  health  should  invariably  be  resorted  to. 
Should  these  measures  fail,  in  order  to  obviate  the 
dangers  of  retention  of  pus,  trephining  about  a  quarter 
of  an  inch  behind  the  meatus  and  a  little  below  the 
level  of  its  upper  wall,  or  the  removal  of  carious  bone 
by  knife  or  probe  is  necessary. 

Polypi  of  the  ear,  generally  due  to  catarrh  there- 
from, are  composed  of  tissue  which  is  either  (1)  soft  and 
granular ;  (2)  mucous ;  (3)  fibrous ;  (4)  hyaline  or 
gelatiniform  or  myxomatous,  the  last  being  the  rarest. 
Their  common  seat  is  the  tympanum. 

Granulation  tissue  in  the  ear,  if  not  amenable  to 
the  treatment  for  aural  catarrh,  or  to  the  instillation 
of  rectified  spirit,  or  touching  with  perchloride  of  iron, 
may  require  removal  by  scraping. 

For  the  larger  polypi  excision  with  a  snare  such  as 
Wilde's,  and  subsequent  cauterisation  of  the  root  with 
saturated  solution  of  nitrate  of  silver  with  chloracetic 
or  chromic  acid,  and  removal  of  the  cause,  comprise 
appropriate  treatment.  Mucous  polypi  may  be  shrunk 
or,  if  small,  obliterated  by  re2:)eated  instillation  of 
rectified  spirit. 

Abscesses  of  the  brain  due  to  ear  disease 
are  usually  single,   and   situate  in   the   whit'^^  matter 


MENf'kRE\'^    D/SFASK.  537 

of  the  hinder  part  of  the  middle  lobe,  the  posterior 
lobe,  or  the  cerebellum. 

Pain  in  the  ear,  if  not  the  result  of  a  recog- 
nisable affection  of  the  meatus,  points  either  to  simple 
catarrh,  or  to  more  or  less  acute,  and  hence  dangerous, 
otitis  interna.  Pain  caused  by  an  affection  of  the  ear 
may  not,  however,  be  distinctly  referable  to  that  organ. 
Conversely,  aural  neuralgia  may  be  caused  by  dental 
caries  or  by  general  malarial  poisoning. 

Disease  of  the  internal  ear,  i.e.  of  the 
labyrinth  and  its  contained  structures,  rarely  primary, 
is  secondarily  of  either  traumatic  or  constitutional 
origin.  Traumatic  causes  are  repeated  concussive 
shocks,  injuries  to  the  brain,  or  local  lacerations,  and 
eflfusion  of  blood  or  serum  ;  and  the  constitutional 
include  developmental  defects,  exposure  to  cold, 
rheumatic  degeneration,  middle  ear  affections,  fevers, 
mumps,  syphilis,  meningitis,  and  sometimes  tabes 
dorsalis.  Lesion  of  the  internal  auditory  apparatus 
is  distinguished  by  deficient  perception  of  both 
3ranially  and  aerially  conducted  vibrations  ;  the  patient 
suffers  from  true  nervous  deafness.  Nervous  deafness 
dependent  on  hypersemia  of  the  labyrinth  is  at  once 
relieved  by  leeching  and  blistering  behind  the  ears. 

Meniere's  disease  is  by  some  authors  under- 
stood to  be  simply  haemorrhage  into  the  semicircular 
canals  ;  by  others  it  has  been  more  comprehensively 
defined  as  an  abnormal  nervous  irritation  in  the  semi- 
circular canals,  or  inflammation  in  these  or  the  middle 
ear,  causing  vertigo.  Its  vital  or  medullary  symptoms 
{e.g.  faintness,  perspiration,  iiTegularity  of  pulse) 
have  been  held  due  to  affection  of  the  cochlear  nerve, 
and  its  locomotor  or  cerebellar  symptoms  (vertigo 
with  or  without  reeling)  to  affection  of  the  semicircular 
canals.  In  cases  regarded  as  typical  the  giddiness  is 
usually  preceded  by  a  feeling  of  vertical  rotation,  and 
is   accompanied   by   tliat    of    foiward    and    backward 


538  Manual  of  Surgery. 

movement  about  a  transverse  axis.  Subjective 
auditory  sensations  are  common.  The  attacks  tend 
to  merge  into  an  habitual  vertiginous  state.  Counter- 
irritation  behind  the  ears,  large  doses  of  potassium 
bromide,  and  also  quinine  and  ammonium  chloride,  are 
useful  in  many  instances.  As  vertigo  may  be  pro- 
duced in  a  variety  of  ear  lesions,  the  discovery  and 
treatment  of  the  cause  must  be  aimed  at. 

Electricity  in  aui'al  disease.— The  induced 
electrical  current  has  been  successfully  employed  in 
several  cases  of  intratympanic  disease ;  and  stimula- 
tion of  the  ear  muscles  by  the  continuous  current  is 
sometimes  beneficial. 

Tinnitus  aurium,  or  persistent  subjective  sound 
in  the  ears,  when  not  ascribable  to  sympathetic  or 
to  cerebral  stimulation  of  the  auditory  nerve,  would 
appear  to  be  usually  the  result  of  abnormal  pressure 
upon  the  labyrinthine  nerve  fibres,  which  again  is 
generally  due  to  some  afiection  of  the  drum-head.  It 
may  be  dependent  on  spasm  of  the  tensor  tympani  and 
stapedius,  or  on  the  existence  of  free  fluid  in  the 
tympanum,  and  may  occur  also  as  a  symptom  in 
various  disturbances  of  the  circulation,  in  debility, 
alcoholism,  exophthalmos,  and  other  conditions.  For 
its  alleviation  have  been  employed  medicinally 
pilocarpine  injections,  zinc  valerianate,  digitalis,  arnica, 
ammonium  chloride,  quinine  and  morphia  combined, 
and  hydrobromic  acid,  and  locally  chloroform  vapour 
and  warm  glycerine  and  laudanum  for  the  meatus, 
strychnine  solution  injected  through  the  Eustachian 
catheter,  the  air  douche,  faradisation,  and  section  of 
the  posterior  fold  of  the  membrane.  Autophony,  or 
the  hearing  of  one's  own  voice  in  the  head,  a  symptom 
in  sundry  aural  afiections,  appears  to  result  from 
defective  mechanical  action  of  the  membrana  or  the 
ossicles. 

Deaf  mutism,    or    deaf-dumbness,    afifects    on 


Deaf  Mutism,  539 

an  average  one  person  in  some  1550,  and  males 
more  than  females.  It  is  congenital  or  acquired, 
according  as  produced  by  causes  arising  before  birth 
(consanguinity,  heredity,  syphilis,  inebriety,  e.g.^  or 
after  birth  (as  fevers,  scrofula,  catarrhal  inflammation, 
and  falls  and  blows).  It  is  rare  that  the  immediate 
parents  of  deaf  mutes  are  deaf  and  dumb.  For  the 
acquisition  of  speech  by  deaf  mutes  the  German  or  pure 
oral  method  is  that  best  adapted,  the  pupil  learning 
both  by  personal  practice  and  by  ocular  demonstration 
(lip-reading)  the  mechanism  of  speech. 

Instmineiital  aids  in  deafness. — Of  the 
various  instruments  for  the  improvement  of  hearing 
by  reflection  of  sound  a  hollow  cone  is  the  simplest 
and  most  eflScient.  Small  globose  or  conical  resonatora 
may  be  of  great  benefit.  Hearing  through  the  teeth 
may  be  rendered  possible  by  the  use  of  the  audiphone 
or  one  of  its  numerous  modifications. 


540 


XIV.     DISEASES   OF   THE   EYE. 

E.  Marcus  Gunn. 

Diseases  of  the  Eyelids. 

Anatomically  the  eyelid  is  a  complex  structure,  and 
its  diseased  conditions  are  corresjDondingly  varied  in 
character  ;  its  skin  and  cutaneous  glands,  conjunctival 
mucous  membrane,  muscles,  Meibomian  glands,  tarsal 
"cartilage,"  and  eyelashes,  with  their  follicles  and 
sebaceous  glands,  are  all  liable  to  be  affected.  Again, 
the  position  of  the  lid  is  such  that  any  departure 
from  the  healthy  condition  readily  causes  discomfort. 
Paralysis  of  the  muscles  and  affections  of  the  con- 
junctiva of  the  lid  will  be  more  appropriately  con- 
sidered later. 

Blepharitis. — The  edges  of  the  lids  are  specially 
prone  to  disease,  and  principally  to  a  chronic  form  of 
inflammation  known  as  marginal  blepharitis.  In  the 
more  severe  forms  of  this  affection  the  palpebral  border 
is  dusky-red,  swollen,  and  covered  with  hard,  dark 
yellow  crusts.  On  removing  these  latter  a  moist 
surface  is  exposed,  often  with  ulceration  or  small 
yellow  pustules  round  the  insertion  of  eyelashes ; 
sometimes  there  is  eczema  of  the  neighbouring  skin. 
If  neglected,  the  ulcers  may  damage  or  even  destroy 
the  cilia  follicles,  leading  to  badly  developed,  misplaced 
lashes  {trichiasis),  or  to  more  or  less  complete  absence 
of  them.  Sometimes  we  get  ectropion  from  hyper- 
trophy of  the  conjunctiva,  and  epiphora  from  eversion 
of,  or  other  interference  with,  the  puncture.  In  the 
milder  forms  there  is  hypersecretion  from  the  seba- 
ceous glands,  leading  to  the  formation  of  small, 
yellowish-white  crusts,   on    removing  which  we  find 


Stye. 


541 


the  underlying  surface  somewhat  reddened  but  not 
ulcerated.  Sometimes  we  have  mere  redness  of  the 
edges  of  the  lids,  especially  in  persons  with  delicate 
skin  and  light  complexion,  often  asse)ciated  with  some 
error  of  refraction  and  consequent  straining  of  the 
eyes.  This  condition  is  also  liable  to  be  caused  by 
external  irritation,  as  exposure  to  dust  or  cold.  The 
more  severe  cases  usually  occur  in  strumous  children, 
and  frequently  date  from  an  attack  of  measles. 

Treatment. — In  all  cases  we  must  attend  to  the 
general  condition  of  the  patient,  syrup  of  the  iodide  of 
iron  or  other  chalybeate  being  frequently  indicated. 
External  irritants  and  over-use  of  the  eyes  are  to  be 
avoided,  and  glasses  ordered  if  necessary.  Locally, 
our  treatment  must  be  directed  principally  to  re- 
moving the  crusts  and  preventing  their  re-formation. 
Warm  alkaline  lotions  {e.g.  10  gr  of  biborate  of  soda 
to  the  ounce  of  water)  are  to  be  used  several  times 
daily,  the  softened  crusts  then  picked  ofF,  and  dilute 
nitrate  of  mercury  ointment  (1  part  to  7  of  vaseline) 
applied  to  the  roots  of  the  lashes.  In  very  severe 
cases  all  the  affected  lashes  should  be  pulled  out  and 
the  excoriated  surface  of  the  lid  touched  with  a  strong 
solution  of  nitrate  of  silver  (20  gr.  to  the  ounce). 
When  the  lashes  have  been  destroyed  and  the  lids 
everted  (lippitudo)  we  cannot  hope  to  restore  a  healthy 
condition,  but  cleanliness,  astringent  lotions,  and 
slitting  the  everted  canaliculi  will  cause  much  im- 
provement. 

The  crab-louse  occasionally  takes  up  its  abode  on 
the  edge  of  the  lids,  and  its  eggs  are  then  found  dis- 
posed along  the  sides  of  the  lashes  like  little  dark 
beads.  At  a  superficial  glance  the  condition  might  be 
mistaken  for  blepharitis,  or  dirt  on  the  lashes.  The 
use  of  a  mild  mercurial  ointment,  such  as  that  men- 
tioned above,  will  soon  kill  the  pediculi. 

ITordeoliim,  or  stye,   is  a  circumscribed  hard 


542  Manual  of  Surgery. 

swelling  at  the  outer  edge  of  the  margin  of  the  lid, 
due  to  a  suppurative  inflammation  of  one  of  the  seba- 
ceous glands  at  the  roots  of  the  lashes.  There  is  con- 
siderable pain  at  first,  and  marked  swelling  from 
infiltration  of  the  adjacent  loose  tissue  of  the  lid.  The 
most  severe  cases  are  of  the  nature  of  boils ;  in  these 
the  pain  is  very  acute,  and  there  is  often  considerable 
chemosis  of  the  conjunctiva. 

Treatment. — In  an  early  stage,  touching  the  part 
with  nitrate  of  silver,  pulling  out  the  corresponding 
eyelash,  and  using  lead  lotion,  often  cut  short  the 
inflammation.  Later  on,  warm  applications  are  useful 
in  soothing  the  pain  and  in  hastening  the  suppurative 
process.  When  pus  has  formed  it  should  be  evacuated. 
General  treatment  is  often  indicated  by  the  condition 
of  the  patient,  mild  purgatives,  iron,  and  nitro-hydro- 
chloric  acid  being  frequently  serviceable.  Some  young 
adults  are  particularly  subject  to  styes  occurring  in 
successive  crops,  and  the  local  treatment  of  most 
service  in  such  cases  is  the  use  of  an  eye  douche,  with 
lead  lotion.  Styes  are  sometimes  associated  with  an 
error  of  refraction,  which  should  be  corrected  by  the 
necessary  glasses.  At  other  times  they  are  dependent 
on  some  defect  in  the  general  health,  or  on  local 
irritation,  as  from  blepharitis. 

Distichiasis  and  tricUiasis  are  terms  used  to 
signify  difierent  forms  of  displacement  of  the  eyelashes 
produced  by  disease.  In  the  former  condition  they 
are  disposed  in  a  more  or  less  complete  double  row, 
while  in  the  latter  they  are  obliquely  placed  and 
often  stunted  ;  in  both  afiections  some  of  the  displaced 
lashes  rub  against  the  cornea  and  thus  set  up  irritation, 
sometimes  leading  to  pannus  and  even  ulceration. 
The  usual  causes  of  trichiasis  are  blepharitis  and 
trachoma. 

Treatment.  —  Temporary  relief  can  always  be 
afforded  by  epilation  of  the  misplaced  lashes.     The 


Entropion. 


543 


more  radical  operations  consist  either  in  destroying  the 
cilia  at  fault  or  in  giving  them  a  new  position.  If 
there  be  only  one  or  two  lashes  actually  rubbing  on 
the  cornea,  we  may  destroy  their  follicles  by  electro-  ' 
lysis.  In  more  severe  cases  we  may  remove  all  the 
offending  lashes  and  their  bulbs  by  judicious  excision 
of  part  of  the  lid  margin.  The  number  of  methods 
that  have  been  devised  with  the  object  of  transplanting 
the  misplaced  lashes  outwards,  suggests  the  unsatisfac- 
tory nature  of  the  results  usually  obtained.  For  an 
account  of  these  operations  the  reader  must  be  referred 
to  special  text-books  on  ophthalmic  surgeiy. 

Ankylo-blepharon,  or  union  of  the  edges  of  the 
upper  and  lower  lids,  may  be  congenital,  but  generally 
arises  from  injuries  (wounds  or  bums)  or  from  ulcera- 
tion. It  is  rarely  complete.  Division  of  the  adhesions 
with  scissors,  and  attention  for  a  few  days  so  as  to 
prevent  reunion,  will  generally  effect  a  cure. 

Entropion,  or  inversion  of  the  lid  margin,  may 
affect  either  the  upper  or  lower  eyelid,  but  its  nature 
usually  differs  in  the  two  cases.  It  always  causes  much 
discomfort  from  the  rubbing  of  the  lashes  against  the 
cornea.  Entropion  of  the  lower  lid  generally  occurs 
in  old  people,  and  is  then  due  to  a  spastic  contraction 
of  the  palpebral  fibres  of  the  orbicularis  muscle  in 
association  with  loose  senile  tissues.  It  may  be 
relieved  by  excision  of  a  strip  of  skin  and  orbicularis 
along  the  whole  length  of  the  lid,  a  little  below  its 
margin ;  sutures  may  or  may  not  be  employed. 

We  also  occasionally  get  a  spasmodic  entropion 
of  the  lower  lid  from  the  prolonged  use  of  bandages, 
as  after  cataract  extraction.  Generally,  repeatedly 
brushing  a  little  collodion  outside  the  lid,  a  little 
below  the  lashes,  is  sufficient  to  relieve  it,  and  in  any 
case  it  soon  disappears  on  discontinuing  the  use  of  the 
bandage.  Entropion  of  the  upper  lid  is  usually 
organic,    due    to    a    cicatricial    contraction    of    the 


54-1  Manual  of  Surgery. 

conjunctiva  and  inversion  of  the  tarsus  from  burns 
or  old  trachoma.  Relief  can  be  obtained  by  radical 
removal  of  all  the  lashes,  or  by  cutting  or  grooving 
the  "  cartilage "  as  in  Burow's  and  Streatfeild's 
operations. 

Ectropion,  or  eversion  of  the  lid  margin,  may 
be  caused  by  chronic  marginal  blepharitis,  or  by  relaxed 
tissues  in  old  age,  or,  again,  by  cicatricial  contraction 
(as  from  burns  or  wounds,  or  from  abscesses  in  caries 
near  the  orbital  margin) ;  or  it  may  be  due  to  a  rapid 
hypertrophy  of  conjunctiva,  as  sometimes  occurs  in 
purulent  ophthalmia.  The  lower  lid  is  most  frequently 
affected.  This  condition  often  produces  much  de- 
formity, the  conjunctiva  is  usually  inflamed,  and  the 
eversion  of  the  puncta  causes  the  tears  to  flow  over 
the  cheek. 

Treatment. — In  the  non- cicatricial  cases  we  can 
{a)  remove  a  horizontal  strip  of  the  everted  conjunctiva 
and  trust  to  the  subsequent  contraction  drawing  the 
lid  into  position  ;  or  (6)  we  may  shorten  the  lid  by 
remo'dng  a  V-shaped  piece  of  its  entire  thickness  and 
bringing  the  edges  together  with  sutures  or  a  hare-lip 
pin.  Cicatricial  ectropion  may  affect  either  lid, 
and  is  often  only  partial.  The  remedial  operation 
necessary  must  therefore  be  determined  by  the 
particular  case,  but  the  method  most  frequently 
useful  in  ectropion  of  the  lower  lid  is  that  known  as 
the  V-Y  operation. 

Blepharospasm  is  a  spasmodic  contraction  of 
the  orbicularis  muscle,  usually  a  reflex  result  of 
irritation  of  the  fifth  nerve.  It  may  occur  from  a 
foreign  body  in  the  eye,  a  phlyctenule,  etc.,  or  from 
caries  of  the  teeth.  In  other  cases  there  is  pain  or 
pressure  over  the  supra-orbital  or  other  branch  of  the 
fifth,  while  occasionally  it  is  met  with  in  weak 
hysterical  subjects  without  any  evident  local  cause. 

The  treatment  must  be  determined  b^  the  cause. 


Ptosj6. 


545 


In  cases  dependent  on  ocular  conditions  any  foreign 
body  present  must  be  removed,  and  in  phlyctenules 
great  relief  is  afforded  by  the  use  of  cocaine  and 
atropine.  Counter-irritation  by  blister  or  seton,  and 
the  cold  face-douche  are  also  often  of  great  service. 
In  severe  cases  that  do  not  yield  to  other  treatment 
eanthoplasty  is  useful,  the  external  canthus  being 
divided  with  scissors,  and  the  adjacent  conjunctiva 
united  by  suture  with  the  apex  of  the  incision. 

Ptosis,  or  drooping  of  the  upper  eyelid,  may  be 
mechanical,  congenital,  or  paralytic.  The  latter 
form  will  be  considered  later.  Ptosis  may  be  said  to 
be  mechanical  when  it  occurs  in  association  -wdth  a 
shrunken  globe  or  empty  socket ;  or,  again,  in 
trachoma,  where  it  is  due  to  relaxation  of  the  upper 
conjunctival  fold  and  increased  difficulty  of  elevation 
of  the  lid  from  its  gi-eater  weight.  The  congenital 
form  is  often  unilateral  and  varies  in  degree.  It  is 
said  to  be  due  to  imperfect  development  of  the  levator 
muscle.  In  these  latter  cases  the  appearance  may  be 
improved  by  the  removal  of  an  oval  piece  of  skin 
from  the  upper  lid,  so  as  to  cause  the  shortening 
desired ;  but  care  must  be  taken  not  to  leave  the 
cornea  permanently  exposed  by  removing  too  much. 

Certain  other  congenital  anomalies  are  to  be  met 
with  in  the  eyelids,  and  may  be  mentioned  here. 
Coloboma  appears  as  a  wedge-shaped  fissure,  and  is 
usually  in  the  upper  lid.  The  treatment  consists  in 
paring  the  edges  and  uniting  them  with  sutures.  In 
very  rare  cases  the  lids  are  completely  absent. 
£picaiithus  consists  in  a  fold  of  skin  passing  from 
the  side  of  the  nose  to  the  inner  end  of  the  eyebrow 
«ind  concealing  the  inner  canthus.  It  commonly  dis- 
ftppeai-s  as  the  bridge  of  the  nose  is  developed ;  but 
should  it  not  do  so  the  defoiTnity  may  be  removed  by 
excising  a  vertical  elliptical  fold  of  skin  from  the 
upper  part  of  the  nose. 
J  J— 21 


54^  Manual  of  Surgery 

ChalaxJon,  or  Meiboiisian  cyst,  generally 
appears  as  a  hard,  round,  painless  tumour  in  the 
substance  of  the  lid,  about  the  size  of  a  split  pea, 
and  its  position  is  recognised  on  everting  the  lid  by  a 
greyish  semitranslucent  patch  in  an  area  of  increased 
conjunctival  vascularity.  It  is  due  partly  to  an 
hypertro})hy  of  the  Meibomian  gland,  partly  to 
retention  of  its  secretion  and  a  chronic  inflammation 
of  the  surrounding  tissues.  Occasionally  it  inflames 
acutely,  and  may  then  point  cutaneously.  Where 
})0ssible  it  is  always  best  to  open  it  by  a  crucial  con- 
junctival incision  and  remove  all  the  contents  with  a 
scoop.  They  often  occur  in  crops,  and,  like  styes,  are 
especially  frequent  in  young  adults. 

The  other  tumours  which  are  not  infrequently 
found  on  the  eyelid  are  milium,  molluscum  contagiosum, 
xanthelasma,  and  naevus.  Their  character  and 
appropriate  treatment  are  the  same  as  when  they 
occur  in  other  situations,  and  do  not  demand  further 
description  here.  In  this  region  we  may  also  get 
congenital  dermoid  tumours,  warts,  fatty  tumours, 
and  more  rarely  sarcoma  and  epithelioma.  The  eye- 
lid is  a  favourite  situation  for  rodent  ulcer,  while  not 
infrequently  we  also  find  here  primary  and  tertiaiy 
syphilitic  sores  and  lupus. 

Diseases  of  the  Lacrymal  Apparatus. 

The  lacrymal  gland  is  rarely  acutely  inflamed. 
We  then  find  localised  symptoms  of  inflammation,  the 
pain  often  very  severe,  and  pus  generally  soon  forms. 
It  should  be  evacuated  by  early  incision,  as  fistula 
may  be  the  result  when  the  pus  is  allowed  to  find  its 
own  way  out. 

Chronic  inflammation  of  tlic  lacrymal 
g^land  is  more  commonly  met  with,  and  is  recognised 
by  a  circumscribed  hard  swelling  in  the  upper  outer 
pai't  of  the  orbit,  the  enlargement  being  visible   in 


HPIPHORA.  547 

this  part  of  the  conjunctival  fornix  on  everting  the 
upper  lid.  We  sbould  try  to  produce  absorption  by 
local  application  of  iodine  or  mercurial  ointments. 
If  pus  forms  it  is  to  be  evacuated  as  in  acute  cases. 
Very  rarely  we  get  a  blueish  translucent  swelling  in 
the  same  position,  viz.  up  and  out,  a  retention  cyst  in 
connection  with  the  gland  ducts  (dacryops).  A  small 
seton  placed  and  tied  loosely  in  the  anterior  wall  of 
the  cyst,  and  allowed  to  ulcerate  through,  is  a  good 
method  of  treating  this  affection. 

The  tiiinoiu's  most  liable  to  occur  in  the  gland 
itself  are  cysts  and  sarcomata.  "When  necessary  the 
gland  can  be  extirpated  through  an  incision  at  the 
outer  orbital  margin  above. 

Epiphora. — In  by  far  the  greater  number  of  cases 
of  lacrymal  disorder  the  drainage  of  the  teai-s  is  defec- 
tive, in  consequence  of  which  they  run  over  the  cheek, 
and  we  get  the  condition  known  as  epiphora,  stilli- 
cidium  lacrimarum^  or  "  watery  eye."  In  such  cases 
it  is  well  always  systematically  to  examine  each  part 
of  the  ch-ainage  system  in  the  natural  order  of  the 
passages  from  above  downwards. 

Eii'st,  then_,  one  of  the  pw?icfa  may  be  at  fault, 
(a)  from  disj^tlacement,  as  in  ectropion ;  or  (h)  it  may 
be  obstructed  by  the  presence  of  a  foreign  bo^Iy,  e.g. 
an  eyelash;  or,  again,  (c)  the  puncta  may  be  narrowed, 
sometimes  even  quite  occluded,  as  a  congenital  mal- 
formation or  as  the  result  of  old  inflammation. 

Kext,  the  canaliculus  may  be  obstructed  by  a 
chalky  concretion  or  by  a  fungoid  growth  (leptothrix)  ; 
or,  again,  its  calibre  may  be  narrowed,  either  from 
swelling  of  its  mucous  membrane,  as  in  chronic 
blepharitis,  or  from  cicatricial  contraction,  the  lesult 
of  a  former  inflammation.  The  most  common  posi- 
tion of  stricture  is  just  at  its  entrance  into  the  sac. 

The  sac  is  subject  to  a  chronic  form  of  blen- 
orrhcea    and   to   acute    inflammation.       The    former 


548  Manual  of  Surgery. 

condition  is  generally  either  the  result  of  extension 
of  inflammation  from  the  conjunctiva  or  from  the 
Schneideiian  membrane,  or  it  begins  as  a  simjjle  dis- 
tension of  the  sac^  due  to  stricture  of  the  nasal  duct 
below.  The  increased  secretion  of  mucus  from  its 
thickened  walls  sc-on  bulges  the  sac,  and  we  find  a 
swelling  at  the  inner  canthus  which  can  generally  be 
dispei-sed  by  pressure  {mucocele).  The  contents  can  thus 
usually  be  forced  backwards  through  the  canaliculi,  and 
are  either  clear,  or  turbid  from  admixture  of  pus. 

Acute  dacryocystitis,  or  lacrymal  abscess,  is 
generally  the  result  of  suppuration  of  a  mucocele. 
There  is  brawny  swelling  and  redness  of  all  the 
adjacent  part  of  the  face,  often  extending  to  the 
bridge  of  the  nose  and  half  across  the  cheek ;  but  its 
most  prominent  part  corresponds  to  the  position  of 
the  sac,  where  the  shining  red  skin  seems  ready  to 
burst.  There  is  much  pain,  and  considerable  general 
disturbance.  If  left  to  itself  the  pus  finds  its  way 
through  the  skin  over  the  sac,  but  often  burrows  for  a 
considerable  distance  before  doing  so,  thus  leaving  a 
large  ragged  sore ;  the  cicatrix  left  is  always  a  source 
of  deformity,  and  often  we  get  a  troublesome  fistula 
in  addition. 

Sti'icture  of  the  nasal  duct  may  affect  any 
part  of  it,  but  most  commonly  occurs  just  below  the 
sac.  It  may  be  caused  by  a  uniform  cii'cumscribed, 
or  by  a  valvular  swelling  of  the  mucous  membrane, 
by  fibrous  contraction  of  the  submucous  tissue,  or  by 
bony  outgrowths.  The  etiology  of  the  affection  is 
obscure,  but  some  cases  can  be  traced  to  a  syphilitic 
or  stmmous  periostitis,  or  necrosis,  and  others  to  an 
pxtension  of  inflammation  from  the  nasal  mucoua 
membrane. 

Treatment* — Foreign  bodies  in  the  puncta  or 
canaliculi  must  be  removed,  the  latter  being  slit  up  if 
necessary.     A  narrowed  i^unctiiia  may  be  dilated  by 


Conjunctivitis.  549 

a  fine  conical  sound,  or  enlarged  by  incision.  In 
epiphora  from  ectropion  the  canaliculus  should  be  slit 
along  its  entire  length,  and  the  same  treatment  must 
be  followed  in  stricture  of  the  canaliculus.  In  all 
cases  of  mucocele  and  stricture  of  the  nasal  duct  the 
upper  or  lower  canaliculus  is  to  be  divided  with  a 
Weber's  knife,  and  a  probe  passed.  The  probing 
should  be  repeated  in  a  few  days,  and  the  interval 
gradually  increased  to  a  week  or  month  as  the  case 
improves.  The  probe  used  should  be  fairly  large  if 
it  will  pass  without  force,  a  convenient  size  being  No. 
5  or  6,  of  the  bulbous-ended  kind  known  as  Couper's. 
Washing  out  the  sac  and  duct  with  boracic  acid  lotion 
is  also  useful,  and  a  weak  astringent  should  be  ordered 
for  the  conjunctiva.  In  cases  of  laciymal  abscess, 
when  still  possible,  the  canaliculus  should  be  slit  and 
the  knife  passed  down  the  duct  so  as  to  divide  the 
anterior  wall  of  the  sac.  Warm  lead  lotion  is  a  ijood 
application  afterwards.  If  the  case  be  far  advanced 
and  pus  already  pointing,  an  incision  should  be 
made  into  the  sac  ^\T.th  a  Beer's  knife,  and  warm  ap- 
plications used  ;  when  the  swelling  has  somewhat  sub- 
sided the  canaliculus  is  to  be  slit  and  the  duct  probed. 

Diseases  op  the  Conjtjxctiva. 

The  conjunctiva  is  subject  to  inflammation  of 
different  forms  and  of  varied  degrees  of  severity,  to 
all  of  which  the  term  '^  o^jhthalmia  "  is  often  applied. 
While  usually  the  whole  membrane  participates,  cer- 
tain kinds  of  conjunctivitis  are  localised,  at  least  at  first. 

Simple  catarrhal  conjunctivitis* — Symp- 
toms. The  whole  conjunctiva  is  much  congested,  often 
showing  patches  of  ecchymosis  ;  there  is  considerable 
mucc-purulent  discharge.  The  lids  are  somewhat 
swollen,  soft,  and  discoloured,  and  on  first  waking 
from  sleep  theu*  edges  are  glued  together.  Occasion- 
ally in  children  an  easily  detached,  sharply   limited 


55©  Manual  of  Surgery. 

membrane  is  formed  on  the  palpebral  conjunctiva,  to 
be  carefully  distinguislied  from  that  found  in  the 
diphtheritic  form.  The  disease  runs  its  course  in  from 
eight  to  fourteen  days,  and  nearly  always  attacks 
both  eyes.  Corneal  affections  are  rare.  The  patient 
complains  of  a  burning,  gritty  sensation,  aggravated 
at  night  and  on  exposure  to  light. 

Causes. — It  is  exceedingly  contagious,  and  is  very 
a])t  to  spread  when  once  introduced  into  a  household  or 
school.  It  is  liable  to  occur  at  all  seasons  of  the  year, 
but  is  especially  common  in  early  summer  and  late 
autumn.  Its  etiology  is  obscure;  sometimes  it  seems 
traceable  to  a  sudden  change  of  temperature,  as  on 
cominof  into  an  overheated  room  from  the  cold  outer  air. 

The  treatment  consists  in  using  a  cold  astringent 
lotion  (3  gTains  of  alum  or  1  gi'ain  of  sulphate  of  zinc  to 
1  oz.  of  water)  several  times  daily,  and  in  applying 
vaseline  to  the  edges  of  the  lids  at  bed  time,  so  as  to 
prevent  gumming. 

Purulent  op!ttl«a!niia  (conjunctival  blenor- 
rhoea). — At  first  the  subjective  symjjtoms  are  like 
those  in  the  catarrhal  form  (sensations  of  burning  and 
grittiness),  but  soon  there  is  generally  severe  pain  in 
and  over  the  eye,  becoming  less  as  the  discharge  be- 
comes more  profuse.  The  lids  are  swollen,  red,  and 
tense,  the  upper  being  also  much  elongated,  so  that  in 
severe  cases  it  cannot  be  fully  everted  nor  the  eye 
fully  exposed.  The  entire  conjunctiva,  both  pal- 
pebral and  ocular,  is  much  swollen  and  injected,  the 
latter  being  frequently  chemosed  so  as  to  project  over 
the  corneal  margin.  The  secretion  is  at  first  watery, 
soon  becomes  opaque  and  whey-like,  and  is  finally 
thick,  yellow,  and  purulent. 

Course  and  complications. — The  discharge  lessens 
spontaneously  in  the  course  of  a  few  weeks,  and  there 
is  not  much  tendency  to  connective  tissue  develop- 
ment.    The  palpebral  conjunctiva  often  remains  for 


GONORRHCEAL    OPHTHALMIA.  55  I 

some  time  greatly  thickened,  and  its  surface  covered 
with  closely  ])laced  prominent  granulations.  Except 
in  the  most  severe  cases,  the  swelling  and  conjunctival 
injection  disappear,  and  the  secretion  ceases  in  about 
three  weeks  under  treatment,  and  the  lids  gradually 
recover  their  original  smooth  mucous  lining.  Where 
the  chemosis  is  extreme  we  are  apt  to  get  corneal 
complications  from  strangulation  of  the  marginal 
corneal  vessels.  Sometimes  there  is  a  slight  diffuse 
liaze  of  tlie  entire  cornea,  but  this  is  not  so  danger- 
ous as  a  localised  purulent  infiltration.  The  latter 
ulcerates  and  often  leads  to  perforation,  and  sometimes 
to  subsequent  panophthalmitis.  Indeed,  from  the 
nature  of  the  discharge,  any  loss  of  corneal  epithelium 
is  highly  dangerous,  and  we  must  be  exceedingly  care- 
ful to  avoid  causing  an  abrasion  in  our  efforts  to  evert 
the  lids,  and  in  our  use  of  the  brush  or  mitigated 
stick.  Pathologically,  we  find  in  the  acute  stage 
great  hypersemia  of  the  conjunctiva,  witli  increase  of 
its  epithelium  and  hypertrophy  of  papilke.  Lymphoid 
cells  occur  diffusely  both  in  and  beneath  the  epithelium. 

Causes. — Purulent  ophthalmia  results  in  some 
persons  (as  in  subjects  of  chronic  tracljoma)  from  the 
contagion  of  an  ordinary  catarrhal  conjunctivitis,  but 
the  two  best  marked  forms  of  the  affection  are  gonor- 
rhoeal  ophthalmia  and  ophthalmia  neonatorum. 

(ct)  Ooiiorrhceal  oplitlialiiBhi,  is  due  to  inocula- 
tion with  discharge  from  another  similar  case,  or  from 
a  urethral  gonorrhoea.  The  i)atients  are  generally 
young  male  adults.  One  eye  only  is  affected  at  first, 
but  the  other  runs  great  risk  of  infection.  The 
symptoms  are  usually  severe,  and  the  condition  is 
always  a  grave  one,  requiring  every  attention. 

Treatment. — If  one  eye  has  escaped  infection  until 
the  patient  comes  under  observation  our  first  aim  is 
to  protect  this  sound  eye  elliciently.  This  can  be 
done  by  putting  a  pad  of  dry  boracic  acid  wool  over 


552  Manual  of  Surgery. 

the  closed  lids,  and  covering  its  entire  surface  and 
sealing  its  edges  with  collodion.  This  must  be  re- 
moved at  least  once  a  day  for  purposes  of  examination 
and  cleansing,  and  a  fresh  pad  is  to  be  carefully  re- 
applied. A  more  convenient  method  of  protection  is 
by  the  use  of  Buller's  shield,  consisting  of  a  watch- 
glass  inserted  between  two  squares  of  indiarubber 
plaister,  each  of  which  has  a  large  round  hole  in  its 
centre  so  that  the  watch-glass  remains  uncovered  except 
just  round  its  edge.  The  double  square  thus  prepared 
should  be  of  such  a  size  that  when  applied  the  watch- 
glass  is  opposite  the  eye,  the  upper  edge  of  the  square 
just  above  the  eyebrow,  the  inner  along  the  nasal 
bridge,  the  lower  at  least  one  inch  below  the  edge  of 
the  lower  lid,  and  the  outer  beyond  the  external 
orbital  margin.  All  these  edges,  except  the  lower 
part  of  the  outer,  are  then  fixed  securely  in  position 
with  strips  of  strong  adhesive  plaister ;  through  the 
watch-glass  the  eye  can  be  kept  under  observation, 
and  the  patient  can  see  to  feed  himself,  etc.*  The 
patient  should  be  put  to  bed,  an  iced  astringent  lotion 
(four  grains  of  alum  or  one  grain  of  sulphate  of  zinc 
to  the  ounce  of  water)  kept  constantly  applied  over 
the  lids  of  the  inflamed  eye,  and  a  solution  of  chloride 
of  zinc  (two  grains  to  the  ounce)  dropped  into  the  eye 
three  to  six  times  a  day,  the  frequency  varying  accord- 
ing to  the  amount  and  thickness  of  the  discharge. 
The  eye  is  also  to  be  washed  frequently  with  a  cold 
astringent  lotion,  and  as  soon  as  the  discharge  becomes 
thick  the  everted  lids  should  be  painted  once  daily 
with  a  solution  of  nitrate  of  silver  (twenty  grains  to 
the  ounce).  If  the  lids  are  very  tense  and  painful, 
two  or  three  leeches  to  the  temple  are  beneficial. 
Sometimes  it  is  impossible  to  evert  the  upper  lid 
thoroughly :  we  must  then  cut  through  the  external 

*  It  is  well  to  have  these  prepared  beforehand  and  ready  for 
use  when  required. 


Ophthalmia  Neonatorum.  553 

canthus  with  scissoi's,  the  direction  of  the  wound 
being  a  continuation  of  the  curve  of  the  outer  end  of 
the  lower  lid.  If  the  secretion  collects  much  under 
the  lids,  the  conjunctival  sac  should  be  syringed  out 
with  cold  water  two  or  three  times  daily  ;  vaseline 
applied  to  the  edges  of  the  lids  prevents  gumming 
during  sleep.  On  the  appearance  of  localised  corneal 
haze,  with  or  without  ulceration,  the  iced  astringent 
compress  must  be  discontinued,  cold  or  even  hot  poppy 
lotion  being  used  in  its  stead,  and  solution  of  sulphate 
of  eserine  (two  grains  to  the  ounce)  dropped  into  the 
eye  six  times  daily.  The  brushing  of  the  lids  should 
be  continued,  but  we  must  be  very  careful  in  everting 
them,  lest  we  cause  rupture  of  the  affected  corneal 
tissue.  The  chloride  of  zinc  drops  may  be  discon- 
tinued, or  a  weaker  solution  employed,  but  they  do  not 
cause  much  irritation  even  in  cases  of  deep  ulceration. 
Slitting  the  conjunctiva  radially  with  scissors  when 
greatly  chemosed  is  to  be  recommended,  as  it  relieves 
the  tendency  to  strangulation.  The  patient  should 
get  good  diet,  with  tonics  when  considered  necessary, 
and  any  urethral  discharge  must  be  treated  locally. 
A  mercurial  purge  should  be  given  if  the  bowels  are 
constipated  at  first.  When  the  conjunctival  discharge 
has  nearly  ceased  the  lids  may  only  be  brushed  once 
every  second  or  third  day,  and  this  treatment  gradually 
discontinued. 

(6)  Oplitlialmia  neonatorum. — This  is  pro- 
bably always  caused  by  inoculation  with  leucorrhoeal 
or  gonorrhoeal  discharge  during  the  passage  of  the 
head  through  the  vagina.  It  is  usually  first  observed 
about  three  days  after  birth,  and  v^aries  much  in 
severity  in  different  cases  according  to  the  character 
of  the  infecting  secretion,  but  is  seldom  so  severe  as 
the  gonorrhoeal  ophthalmia  of  adults. 

Treatmenit. — Both  eyes  are  generally  affected,  but 
if  one   has  hitherto  escaped  and  the  other  be  severely 


554  Manual  of  Surgery. 

inflamed,  a  protective  of  cotton  wool  may  be  ap- 
plied as  directed  above.  The  afiected  eye  is  to  be 
bathed  frequently  with  cold  astringents  (alum  or 
sulphate  of  zinc),  the  conjunctival  sac  thoroughly 
syringed  out  several  times  daily,  and  vaseline  applied 
to  the  edges  of  the  lids.  If  there  is  much  discharge, 
chloride  of  zinc  drops  should  be  used  four  times  a  day, 
and  in  all  cases,  except  the  very  mildest,  the  lids  are 
to  be  brushed  daily  by  tlie  surgeon  with  solution  of 
nitrate  of  silver.  Periplieral  ulcers  of  the  cornea 
should  be  treated  with  eserine,  as  has  been  recom- 
mended in  gonorrhoeal  ophthalmia,  but  in  central 
ulceration  atropine  is  preferable.  Much  attention 
has  been  recently  drawn  to  the  necessity  of  prophy- 
lactic measures  for  the  prevention  of  this  disease.  It 
is  recommended  that  the  vagina  be  carefully  disin- 
fected before  the  birth,  and  that  the  face  and  eyes  of 
the  newly-born  child  be  thoroughly  cleansed  with 
some  simple  antiseptic  solution. 

Oraiiiilar  oplitlialsiaia  or  traclioiiia. — - 
Symptoms.  The  form  of  this  disease  most  commonly 
met  with  in  this  country  is  a  chronic  one,  charac- 
terised by  thickening  and  vascularity  of  the  conjunc- 
tiva, and  by  the  presence  of  round,  semitranslucent, 
pale  prominences  on  the  inner  surface  of  the  lids. 
From  their  resemblance  to  small  grains  of  boiled  sago 
these  prominences  are  often  called  "the  sago  grain 
granulations."  At  first  they  occur  principally  on  the 
lower  retro-tarsal  fold  of  conjunctiva,  s})reading 
gradually  to  the  same  position  above,  and  finally 
affecting  the  entire  lid  surface.  The  ocular  conjunc- 
tiva often  participates  in  the  vascularity,  and  small 
granulations  may  even  occur  in  it.  We  often  get 
vascularity  and  cloudiness  of  the  upper  part  of  the 
cornea  (pannus),  the  vessels  here  lying  immediately 
beneath  the  ejiithelium  ;  this  condition  sometimes 
extends  over  the  entire  cornea.     Ulcers  are  also  apt 


Trachoma.  555 

to  form  on  the  cornea,  especially  -when  there  are  in- 
verted lashes.  There  is  no  tendency  to  spontaneous 
cure,  and  a  long  continuance  of  the  chronic  changes 
generally  leads  to  entropion,  trichiasis,  and  often 
corneal  mischief  as  just  mentioned. 

Apart  from  direct  infection  by  the  secretion  from 
another  such  case,  the  chief  causes  seem  to  be  prolonged 
exposure  to  a  damp  atmosphere  and  bad  ventilation, 
children  being  most  apt  to  suffer.  Certain  races,  e.g. 
the  Irish  and  Jews,  seem  s})ecially  liable  to  it. 

Pathology. — The  granulations  consist  principally 
of  lymph  cells  superficially,  with  more  and  more  con- 
nective tissue  towards  the  base.  As  the  cells  are 
gradually  transformed  into  connective  tissue,  so  we 
get  finally  a  cicatrix  at  the  seat  of  the  granulation. 
The  submucous  tissue  and  tarsus  are  likewise  at  first 
infiltrated  with  lymph  cells,  so  that  here,  too,  we 
ultimately  get  connective  tissue  contractions,  the  "  car- 
tilage "  also  undergoing  fatty  degeneration.  Pannus 
is  said  to  be  mainly  due  to  the  irritation  produced  by 
the  granulations  of  the  upper  lid  constantly  rubbing 
against  the  corneal  surface  on  every  lid  movement, 
but  possibly  a  more  correct  explanation  would  be  that 
the  general  conjunctival  infiltration  with  lymph  cells 
extends  hither,  and,  on  becoming  organised,  forms  new 
vascular  tissue. 

In  the  acute  form  of  the  disease  the  local  appear- 
ances are  those  of  a  severe  conjunctivitis,  with  de- 
velopment of  the  characteristic  gi-anulations,  but  often 
without  much  purulent  dLscliarge.  Such  an  attack 
may  lead  to  the  chronic  form  of  trachoma,  but  some- 
times it  is  self-curative  from  the  very  violence  of  the 
inflammation  destroying  the  granulations.  Cases  of 
chronic  trachoma  are  liable  to  severe  acute  ophthalmia 
from  comparatively  slight  exciting  causes,  antl  the 
discharge  from  all  such  cases  is  highly  infective,  often 
communicating  the  same  foiTu  of  disease. 


556  Manual  of  Surgery. 

Treatment. — In  acute  trachoma  we  should  first  use 
mild  lotions  {e.g.  boracic  acid  10  gr.  to  the  ounce  of 
water),  but,  if  there  be  much  purulent  discharge  later, 
we  must  brush  the  lids  with  solution  of  nitrate  of 
silver.  Chronic  granulations  are  best  treated  by 
touching  the  everted  lids  mth  the  mitigated  nitrate  of 
silver  stick  (1  of  nitrate  of  silver  and  2  of  nitrate  of 
potash),  and  then  washing  them  with  water.  This 
should  be  repeated  t^^4ce  a  week,  or  oftener,  according 
to  the  severity  of  the  case,  and  a  mild  astringent 
lotion  used  frequently  by  the  patient.  Single  granu- 
lations may  be  destroyed  by  the  actual  cautery.  The 
corneal  ulcers,  entropion,  or  trichiasis,  demand  the 
treatment  proper  for  these  affections ;  if  there  be 
photophoVjia,  dark  glasses  are  useful.  The  ordinary 
partial  (upper)  pannus  usually  disappears  as  the  condi- 
tion of  tlie  lids  improves.  Severe  total  pannus  is 
much  relieved  by  the  excision  of  a  strip  of  conjunctiva 
and  subconjunctival  tissue  of  about  two  lines  in 
breadth  from  immediately  round  the  cornea  (peri- 
otomy).  Benefit  is  also  sometimes  obtained  in  suitable 
cases  by  inoculation  with  pus  from  a  mild  case  of 
ophthalmia  neonatorum.  Recently  an  infusion  of 
jequirity  seeds  has  been  used,  the  purulent  ophthalmia 
so  produced  often  giving  good  results.* 

Diphtheritic  ophthalmia  is  a  very  serious 
disease,  happily  rare  in  this  country.  Symptoms. — 
At  first  the  conjunctiva  in  its  entire  thickness  is  in- 
filtrated with  a  firm  fibrinous  exudation,  rendering 
the  lid  hard  and  stiff,  and  patches  of  the  mucous  sur- 
face are  smooth,  firm,  and  of  a  light  grey  colour.  The 
existence  of  the  exudation  leads  to  pressure  on  the 
vessels,  and  the  conjunctiva  is  found  pale  and  almost 

*  About  45  grains  of  the  decorticised  seeds  are  macerated 
for  twenty-four  hours  in  half-a-pint  of  cold  water,  and  a  little 
of  the  fresh  infusion  applied  to  the  conjunctiva  twice  daily  for 
two  or  three  days. 


Diphtheritic  Ophthalmia.  557 

bloodless  on  tearing  away  a  piece  of  the  superficial 
layer.  The  nutrition  of  the  cornea  is  necessarily 
greatly  interfered  with,  and  sloughing  often  occurs. 
When  this  stage  has  lasted  about  a  week,  the  infiltra- 
tion breaks  down,  and  we  get  a  free  purulent  discharge 
with  red  prominent  granulations.  Finally,  we  may 
get  symblepharon  from  loss  of  large  patches  of  con- 
junctiva and  resulting  cicatricial  changes. 

Causes. — It  often  occurs  in  epidemic  form,  chiefly 
in  spring  and  autumn^  and  usually  attacks  young  chil- 
dren from  two  to  six  years  old.  It  may  be  communi- 
cated by  direct  transplantation  of  membrane,  but  in 
predisposed  individuals  a  purulent  ophthalmia  may  take 
on  this  type.  It  is  more  frequently  a  precursor  of, 
than  secondary  to,  general  diphtheria. 

Treatment. — Protect  the  sound  eye  by  a  pad  of  wool 
as  previously  described.  In  the  first  stage  we  must 
avoid  using  strong  astringents,  especially  nitrate  of 
silver,  and  trust  to  mild  lotions  {e.g.  boracic  acid  or 
quinine)  and  atropine  drops.  Both  ice  and  hot 
fomentations  have  been  recommended  by  different 
surgeons.  Scarifying  the  conjunctiva  and  applying  a 
weak  yellow  oxide  of  mercury  ointment  have  also 
proved  useful.  The  patient's  strength  must  be  sup- 
ported by  nutritious  food. 

Besides  the  above-mentioned  more  severe  and 
definite  forms  of  conjunctivitis  we  frequently  get 
slight  cases  due  to  the  patient's  occupation  or  sur- 
roundings. Thus  dust  of  all  kinds,  smoke,  or  irritat- 
ing vapours  are  apt  to  cause  a  chronic  form  of  con- 
junctivitis, and  not  infrequently  it  is  associated  with 
some  error  of  refraction.  In  the  former  ci\ses  sul- 
phate of  zinc  lotion  (one-half  to  two  grains  to  the 
ounce  of  water)  should  be  used  and  the  cause  removed 
as  much  as  possible,  glasses  being  ordered  where 
required.  Sometimes  on  everting  the  lids  we  find 
small,  gritty,  calcareous  particles  projecting  from  the 


558  Manual  of  Surgery, 

saccules  of  some  of  the  Meibomian  glands  :  these 
should  be  picked  out  with  the  point  of  a  broad  needle. 
Old  people  often  have  a  troublesome  conjunctivitis  in 
the  lower  lids,  commonly  associated  with  slight  ectro- 
pion ;  much  relief  is  obtained  from  lightly  touching 
the  inflamed  surface  once  daily  with  sulphate  of 
copper.  Instillation  of  atropine  sometimes  produces 
severe  irritation  of  both  surfaces  of  the  lids,  and  in 
such  cases  if  a  mydriatic  must  be  used,  daturine  or 
duboisine  is  generally  much  less  irritant.  Eserine 
also  frequently  produces  a  chronic  conjunctivitis  when 
used  for  some  time.  This  unpleasant  effect  may  often 
be  avoided,  in  the  case  of  all  these  applications,  by  dis- 
solving the  salt  in  a  strong  solution  of  boracic  acid 
and  adding  about  one  per  cent,  of  hydrochlorate  of 
cocaine. 

Subcoiijunctival  eccSijTiioses  may  occur  dur- 
ing straining,  as  in  whooping  cough,  or  spontaneously 
without  apparent  cause.  They  undergo  gradual  ab- 
sorption, and  are  of  no  local  importance. 

Xerophtlialmois  is  a  term  applied  to  a  condition 
of  the  conjunctiva  "where  its  surface  is  dry  and  lustre- 
less. Sometimes  it  exists  with  almost  complete  obli- 
teration of  both  upper  and  lower  culs-de-sac,  and  may 
then  be  due  to  old  diphtheritic  ophthalmia  or  lime- 
burns,  or  possibly  to  a  succession  of  attacks  of  pemphi- 
gus. Sometimes  the  patch  is  only  epithelial,  and 
confined  to  an  area  near  the  outer  and  inner  corneal 
margins.  This  form  occasionally  occurs  in  schools 
or  other  public  institutions,  and  is  associated  with 
night-blindness  and  scurvy. 

Treatment. — The  epithelial  cases  are  to  be  treated 
through  tlie  general  health  ;  good  diet  with  vegetables, 
fresh  air,  etc.,  being  most  important.  The  parenchy- 
matous forms  can  only  be  treated  with  palliatives,  a 
lotion  containing  milk,  glycerine,  and  bicarbonate  of 
soda  relieving  the  symptoms  somewhat. 


Pterygium.  559 

Syiiiblcpliaron,  or  adhesion  of  the  palpebral 
and  ocular  conjunctiva,  is  usually  the  result  of  burns 
with  lime  or  hot  metal.  When  its  extent  is  such  as 
to  obscure  vision  or  limit  ocular  movement,  an  operation 
may  be  tried  for  its  relief.  When  partial  and  narrow, 
it  will  be  sufficient  to  strangulate  it  by  a  tight  liga- 
ture. Those  of  larger  size  are  to  be  carefully  dis- 
sected off  the  eye-ball,  and  the  resulting  gap  filled  in 
as  well  as  possible  by  flaps  of  neighbouring  conjunc- 
tiva, or  by  a  piece  of  transplanted  mucous  membrane 
from  the  lip. 

Pteryjfiiiin  is  a  triangular,  vascular  patch  of 
thickened  conjunctiva,  its  apex  usually  encroaching 
on  the  cornea  from  the  inner  or  outer  side.  The 
gi'owth  is  generally  commenced  by  an  adhesion  of  con- 
junctiva to  a  marginal  corneal  ulcer.  If  thought 
necessary,  its  apex  may  be  detached  from  the  cornea 
with  a  scalpel,  the  tumour  dissected  up  to  near  its 
base,  and  then  transplanted  into  a  gap  prepared  for  it 
below  the  cornea. 

Lupus  sometimes  occurs  on  the  palpebral  con- 
junctiva_,  and  is  then  usually  associated  with  lupus  of 
the  skin  or  mouth.  The  aftected  patch  of  conjunctly -a 
is  very  vascular,  and  is  covered  with  small,  soft,  dark- 
red  nodular  outgi-owths.  Scraping  with  a  sharp 
spoon  is  the  best  treatment. 

A  Pinguecula  is  a  small  yellowish  thickening 
of  conjunctiva  near  the  outer  or  inner  edge  of  the 
cornea,  common  in  old  people ;  it  contains  no  fat  as 
the  name  would  imply.  It  is  of  no  importance,  but 
may  be  snipped  off  if  desired. 

The  other  tumours  of  the  conjunctiva  (dermoid, 
cystic,  malignant,  fatty)  are  comparatively  rare,  and 
the  reader  must  be  referred  to  some  of  the  larger  text- 
books on  eye  diseases  for  their  description. 


560 


Manual  of  Surgery. 


Phlyctexular  Affections  of  the  Eye. 

These  affections  are  much  most  frequently  met 
with  in  young  people  between  the  ages  of  three  and 
twelve  years,  and  usually  in  association  with  the 
strumous  constitution.  The  attacks  tend  to  recur 
during  early  life,  such  repetition  being  easily  induced 
by  any  slight  irritation  of  the  eye. 

Varieties  and  symptoms. — Either  the  ocular 
conjunctiva  or  cornea  may  be  the  seat  of  the  phlyc- 
tenule. When  situated  on  the  conjunctiva  quite 
away  from  the  cornea,  it  appears  at  first  as  a  papule 
or  pustule  about  two  mm.  in  diameter,  surrounded 
by  a  localised  patch  of  injection  ;  this  soon  breaks 
down,  and  we  have  a  flat  whitish  ulcer.  There  may 
be  one  or  several  such  pustules,  but  they  seldom  cause 
much  photophobia,  pain,  or  lacrymation,  and  are  gene- 
rally soon  amenable  to  treatment.  Sometimes,  how- 
ever, especially  when  near 
the  corneal  margin,  the 
ulcer  formed  may  run  on 
to  the  cornea,  and  travel 
towards,  or  even  across,  its 
centre.  In  such  cases  the 
ulcer  advances  slowly  in 
the  form  of  a  small  infil- 
trated crescent  with  its 
convexity  forwards,  and 
with  a  vascular  leash  run- 
ning to  its  concavity  over  its  recent  track  from  the 
original  starting  point  (Fig.  119).  There  is  gene- 
rally much  blepharospasm  during  the  attack.  Very 
rarely  a  marginal  pustule,  instead  of  .spreading  super- 
ficially, leads  to  a  perforating  ulcer  at  the  corneal 
edge.  Phlyctenules  at,  or  just  within,  the  margin  are 
usually  small  in  size  and  multiple.  Sometimes  the 
entire  corneal  border  all  round  is  slightly  swollen  and 


Fig.  119- -Vascular  phlyctenular 
Ulcer  of  Cornea.   (After  Travers.) 


Phlyctexulm,  t6i 

vascular,  with  minute  phlyctenular  elevations  like  fine 
sand-grains :  the  conjunctiva  generally  is  usually  in- 
jected in  this  form.  More  commonly,  at  one  or  more 
points  of  the  corneal  margin,  we  find  a  vascular  eleva- 
tion, with  greyish  summit,  about  the  size  of  a  turnip  seed. 
In  all  such  cases  there  is  generally  considerable  pho- 
tophobia^  and  there  are  often  short  relapses  during 
treatment,  but  ultimately  they  as  a  rule  do  welL 
Occasionally,  however,  such  phlyctenules  cause  trouble- 
some ulceration,  but  not  so  commonly  as  those  which 
are  located  quite  within  the  corneal  edge,  and  appear 
first  as  prominent  greyish  opacities  about  the  size  of  a 
small  pin's  head.  In  these  latter  the  blepharospasm, 
pain,  and  lacrj^mation  are  usually  severe. 

Treatment. — In  the  case  of  conjunctival  pustules, 
and  in  other  forms  without  photophoVjia  or  deep 
corneal  ulceration,  the  dilute  yellow  oxide  of  mercury 
ointment  (8  grains  to  the  oimce  of  vaseline)  is  the 
most  suitable  local  remedy.  A  small  piece  of  this 
salve  should  be  laid  within  the  lower  lid  once  or 
twice  daily,  the  upper  lid  then  gently  rubbed  over  the 
eye-ball  for  a  few  minutes  (with  the  finger  placed  on 
its  skin  surface),  and  the  eye  bathed  with  lukewarm 
water  half  an  hour  later,  if  irritation  continues. 
Finely-iwwdered  calomel  dusted  into  the  eye  once 
daily  may  be  substituted  for  the  ointment.  ^Yhere 
there  is  photophobia  the  patient  should  wear  a  large 
shade  or  goggles  over  both  eyes,  and  ati-opine  oint- 
ment (2  grains  to  the  oTince  of  vaseline),  or  a  mixture 
of  equal  parts  of  this  and  the  dilute  yellow  oxide  of 
mercury  ointment,  according  to  the  severity  of  the 
symptcmis,  should  be  applied  twice  daily.  In  the 
vascular  travellinij  ulcer  the  same  local  treatment  is 
good,  combined  with  a  seton  in  the  temple.  Division  of 
the  leash  of  vessels  at  the  corneal  e<lge  is  also  re- 
commended. For  the  small,  multiple,  marginal 
phlyctenules  with   conjunctivitis,   cold   or    lukewarm 

K   K— 21 


562  Manual  of  Surgery. 

boracic  acid  lotion  should  be  used  four  times  daily, 
and  the  atropine  ointment  put  into  the  eye  after 
each  batliing.  The  measures  useful  in  persistent 
blepharospasm  have  been  already  described  under 
that  heading,  (See  page  544.)  Constitutional  treatment 
must  not  be  neglected.  Good  plain  food  (especially 
warm  milk),  with  syrup  of  the  iodide  of  iron,  and  cod- 
liver  oil,  are  indicated,  and  the  patient  should  get 
plenty  of  open-air  exercise,  with  the  eyes  efficiently 
protected.  As  a  rule  such  cases  do  not  do  well  at 
the  sea-side  as  long  as  there  is  much  photophobia. 

Diseases  op  the  Cornea. 

Keratitis. — There  are  several  distinct  forms  of 
corneal  inflammation,  and  each  may  present  varying 
degrees  of  severity.  The  inflammation  may  be  super- 
ficial or  deep,  circumscribed  or  diff'use,  purulent  or 
non-purulent.  Before  considering  the  diflferent  types 
of  keratitis  we  may  briefly  regard  the  subject 
generally. 

The  subjective  symptoms  that  are  usually  asso- 
ciated with  corneal  inflammation  are  pain,  photophobia, 
lacrymation,  and  impairment  of  vision.  The  ^j>am  is 
generally  in  and  around  the  eye,  but  sometimes  may 
be  also  referred  to  the  distribution  of  the  fifth  nerve 
in  the  face  and  temple,  as  where  there  is  associated 
iritis.  The  photophobia  is  really,  more  properly 
speaking,  a  reflex  blepharospasm,  and,  like  the  lacry- 
mation, is  due  to  ii-ritation  of  the  sensory  fifth  nerve 
branches  in  the  cornea.  These  latter  symptoms  are 
usually  most  severe  in  young  patients  and  where  the 
corneal  afiection  is  superficial.  The  impairment  of 
vision  varies  directly  with  the  density  of  the  haze 
produced,  and  its  more  or  less  central  position. 
Locally  we  get  congestion  and  loss  of  corneal  trans- 
parency. Not  infrequently  we  have  iritis  also,  and 
even  where  this  does  not  exist  the    pupil   is  often 


Kera  tit  is. 


563 


small,  probably  a  "  congestion  miosis."  The  nature 
of  the  loss  of  transparency  differs  according  to  the 
corneal    layer    involved    and    the    character   of   the 


Fig.  120.— Vascular  Supply  of  the  Eye-baU. 

a.  Long  posterior  ciliary  artery  ;  h.  vena  vorticosa;  c,  chorio-capillaris ;  d,  epis- 
cleral brancbes  ;  e.  recurrent  cboroidal  artery  ;  /,  vessels  of  ciliary  i>roces.«es; 
g,  anterior  ciliary  arteries  and  veins;  h,  ix)sterior  conjunctival  vessels; 
i,  anterior  conjunctival  vessels ;  k,  marginal  looivplexus  of  cornea  ;  /,  canal 
of  Scbleium  ;  m,  vessels  of  iris.    (After  Leber.    Diagrammatic.) 

inflammation.  "When  the  anterior  ejHthelium  is 
affected  the  surface  looks  steamy  and  finely  pitted. 
Chronic   interstitial    inflammation   .cdves   rise   to   an 


564  Manual  of  Surgery. 

oj>aJescent  haze,  the  anterior  epithelium  soraetimes 
remaining  sound.  A  yellow  opacity  results  from  the 
presence  of  pus  between  the  layers.  Minute  round 
■white  dots  on  the  posterior  surface  are  found  in  in- 
flammation of  the  posterior  epithelium  (keratitis 
punctata).  The  congestion  may  be  deep,  appearing 
simply  as  a  pink  or  lilac  circumcomeal  zone,  e.g.  in 
an  early  stage  of  keratitis,  in  many  cases  of  corneal 
nicer,  etc.,  and  due  to  injection  of  the  episcleral 
branch^  of  the  anterior  ciliary  arteries.  Or  we  have 
a  salmon-coloured  patch  over  part  of  the  cornea  from 
formation  of  new  vessels  in  its  true  stroma,  as  in 
int-erstitial  keratitis.  Again,  we  may  get  a  superficial 
vascular  mound  encroaching  on  the  cnraeal  edge  at 
one  or  two  spots,  or  all  round,  as  in  many  cases  of 
peripheral  ulcer,  and  es-pecially  in  miliary  phlyctenules, 
and  due  to  injection  of  the  marginal  loop-plexus  (Fig. 
120).  Pannus  we  have  already  mentioned  when  speak- 
ing of  trachoma ;  the  new  vessels  under  the  epithe- 
lium are  in  connection  with  the  conjunctival  vessels. 
Pannus  may  also,  less  commonly,  result  from  tri- 
chiasis, entropion,  phlyctenular  keratitis,  chronic 
blenorrhosa,  and  may  occur  during  the  healing 
process  in  corneal  ulcers.  Sometimes  we  also  get 
considerable  conjunctival  injection  in  association  with 
keratitis. 

Causes. — Local  injury,  malnutrition  (local  or 
general),  and  constitutional  diseasa  It  may  likewise 
occur  as  part  of  a  more  general  ocular  inflammation. 
As  examples  of  corneal  inflammation  produced  by 
local  injury,  we  have  ulcei^ation  from  a  foreign  body 
or  abrasion,  and  snppui-ative  interstitial  kei'atitis 
after  cataract  extraction.  As  forms  resulting  from 
local  maJnidrition  we  may  instance  the  severe 
keratitis  met  with  in  ]>urulent  and  diphtheritic 
ophthalmia,  where  infilti-ation  of  the  conjunctiva 
and  subconjunctival  tissue   has  led  to  strangulation  of 


Keratitis.  565 

vessels  round  the  corneal  margin ;  also  possibly  the 
ulceration  often  found  in  cases  of  herpes  frontalis. 
General  malnutrition,  as  a  result  of  over-lactation, 
insufficient  food,  etc.,  is  responsible  for  many  cases  of. 
ulceration,  and  for  the  keratomalakia  met  with 
occasionally  in  puny,  ill-thriven  infants.  The  best 
marked  constitutional  types  of  com^al  inflammation 
are  the  interstitial  keratitis  of  congenital  syphilitics 
and  the  phlyctenular  of  strumous  children.  In  sym- 
pathetic oplithalniitis,  relapsing  cyclitis,  etc.,  the 
corneal  affection  is  /^r??-^  of  a  more  geyieral  ocular 
inflammation. 

The  treatment  will  be  considered  more  par- 
ticularly later ;  but  we  may  say  here  that  hot  fomen- 
tations are  nearly  always  indicated,  and  that  atropine 
is  good  except  where  we  have  increased  tension. 

Results. — There  is  always  more  or  less  opacity, 
which  may  or  may  not  ultimately  clear  up.  Super- 
ficial nebulpe  and  parenchymatous  opacity  from  chronic 
interstitial  keratitis  are  most  likely  to  disappear, 
especially  if  the  patient  be  young.  Sometimes  we 
get  a  staphylomatous  bulging,  as  after  perforating 
ulcer ;  in  other  cases  the  cornea  flattens  and  shrinks 
after  extensive  loss  of  its  substance. 

Varieties  of  keratitis. — 1.  lleers  of  the 
cornea  either  commence  wdtli  a  loss  of  ei>itlielium,  or 
are  formed  by  the  breaking  doNVTi  of  a  circumscribed 
infiltration.  If  much  purulent  infiltration  remains  at 
the  base  and  edges  of  the  ulcer  the  healing  process  is 
generally  less  rapid  and  the  tendency  to  perforation 
greater ;  some  clear  ulcers,  however,  heal  very  slowly. 
In  purulent  ulceration^  or  in  cases  of  corneal  ulcer 
complicated  with  iritis,  we  may  get  a  deposit  of  pus  in 
the  lowest  part  of  the  anterior  chamber  {Jiypopyon). 
If  this  be  quite  fluid,  its  upper  boundary  shows  a  level 
surface,  its  plane  altering  fairly  readily  according  to 
the  position  of  the   patient's  head.     If  it  be  thick, 


566  Manual  of  Surgery. 

consisting  of  puro-lymph,  the  upper  surface  is  more  or 
less  convex  upwards,  and  it  moves  slowly  and  partially 
(if  at  all)  on  changes  in  position.  The  pus  in  hypopya 
may  be  derived  from  the  cornea  or  iris ;  if  from  the 
cornea  it  may  result  from  suppuration  of  its  posterior 
epithelium,  or  may  come  from  an  abscess  that  has 
either  burst  through  the  posterior  surface  or  that  has 
gravitated  interstitially  and  has  filtered  into  the 
chamber  through  natural  sj)aces,  such  as  those  of  the 
ligament\im  pectinatum  iridis.  To  the  gravitated  de- 
posit remaining  between  the  corneal  lamellae  the  term 
onyx  is  applied.  If  the  ulcer  passes  quite  through  the 
parenchymatous  tissue  the  posterior  elastic  lamina 
bulges  into  the  gap,  constituting  a  hernia  comese.  On 
perforation  occurring,  the  aqueous  escapes,  the  pupil 
contracts,  and  the  iris  and  lens  lie  against  the  posterior 
surface  of  the  cornea,  the  iris  often  even  prolapsing 
through  the  aperture ;  in  such  cases  we  occasionally 
get  purulent  inflammation  of  the  iris,  choroid,  and 
vitreous,  and  ultimate  loss  of  the  eye.  During  the 
process  of  healing  of  a  deep  ulcer,  superficial  vessels 
are  formed  on  the  cornea  running  from  the  limbus, 
and  the  base  of  the  ulcer  loses  its  yellow  colour.  As 
a  final  result  we  get  a  clear  facet,  a  nebula,  or  a  more 
or  less  dense  leucoma  (permanent  if  from  a  deep  ulcer); 
where  perforation  occurred  we  usually  have  an  anterior 
synechia. 

Forms  mid  treatment. — Many  distinct  types  of 
corneal  ulcer  "^  occur,  but  for  practical  i:)urposes  we 
may  (with  one  exception,  to  be  considered  later)  divide 
them  into  sui^erjicial  and  deej)^  central  and  'peripheral^ 
clear  and  infiltrated.  Chronic  clear  superficial  ulcers 
require  local  stimulation,  as  with  the  dilute  oxide  of 
mercury  ointment  or  powdered  calomel.  Infiltrated 
ulcers  are  best  treated  with  hot  fomentations,  applied 

*  For  description  and  treatment  of  phlyctenular  vdcers,  see 
page  660. 


Keratitis.  5C7 

every  hour   or    so  for   10  to  20   minutes  at  a  time, 
and  used  as  hot  as  can  be  tolerated ;  in  the  interval 
the  eye  should  be  covered  with  a  firm  pad  of   cotton 
wool.     If  the  ulcer  be  central  or  painful,  belladonna 
fomentation  (3J  of  extract  to  the  pint  of  water),  or  hot 
boracic  acid  lotion  will  be  suitable,  and  atropine  drops 
(4  gr.  to  the  ounce)  instilled  four  to  six  times  daily. 
When  in  the  periphery  of  the  cornea,  and  especially 
where  the  tension  of  the  globe  is  increased,  the  ulcer 
is  best  treated  with  eserine  droi)S  (2  to  4  gr.   to  the 
ounce),  and   hot  boracic  acid  or  poppy  fomentation. 
In  the  case  of  deep  ulcers  with  much  purulent  infiltra- 
tion it  is  well,  first  of  all,  to  scrape  the  base  of   the 
ulcer  with  a  small  sharp-edged  spoon,  so  as  to  remove 
all  the  broken  down  corneal  tissue,  and  afterwards  to 
fill  the  cavity  with  powdered  boracic  acid ;  the  hot 
fomentations  and  atropine  or  eserine  drops  should  then 
be  used.     If  the  ulcer  have  all  but  perforated,  and 
there  be  no  hypopyon,  we  should  prick  the  projecting 
posterior  layer  with  a  sharp  needle.    Whenever  liypo- 
pyon  accompanies  purulent  ulcer  or  corneal  abscess, 
the  most  generally   successful  treatment    consists  in 
cutting  right  through  the  cornea  with  a  narrow  linear 
knife,  the   slit   extending  quite    across    the   inflamed 
area  and  just  into  the  sound  tissue  at  each  side ;  on 
completing    the    section    the    aqueous    escapes    and 
generally  carries  with  it  all,  or  some,  of  the  hypopyon. 
Not  infrequently  a  thick  piece  of  puro-lymph  sticks  in 
the  wound  and  can  be  easily  withdrawn  with  forceps. 
The  exceptional  form  of  ulcer  above  alluded  to  as 
demanding  separate  consideration  is  the  serpiginous 
(ulcus  serpens).     It  generally  begins  as  a  small,  oval 
or  round,   superficial   loss  of    substance,   with    slight 
j)pacity,  usually  near  the  centre  of  the  cornea.    At  one 
or  more  points  along   its   margin  we    find  a  white, 
cheesy-looking,    crescentic    infiltration.       The    ulcer 
spreads  in  the  direction  of  the  infiltrated  crescents, 


568  Manual  of  Surgery. 

and  may  thus  creep  over  the  entire  corneal  surface, 
cicatrising  at  some  places  while  extending  at  others, 
while  it  also  often  tends  to  affect  the  deeper  layers. 
The  symptoms  are  frequently  severe,  i.e.  well-marked 
congestion  and  great  pain.  It  is  apt  to  become  com- 
plicated with  iritis  and  hypopyon,  and  sometimes  per- 
foration takes  place.  Persons  advanced  in  years,  and 
subjects  of  chronic  dacryo-cystitis  are  liable  to  get  this 
foi-m  of  ulcer,  often  from  a  mere  corneal  abrasion.  A 
fungoid  growth  (aspergillus)  is  said  to  be  the  active 
local  cause  of  tlie  ulceration.  In  an  early  stage  the 
treatment  should  consist  in  hot  fomentations  fre- 
quently, atro})ine  four  times  a  day,  and  powdered 
iodoform  dusted  over  the  cornea  twice  daily.  Some 
surgeons  recommend  touching  the  infiltrated  edge  with 
the  actual  or  galvano-cautery.  If  perforation  occur, 
atropine  or  eserine  should  be  used  according  to  its 
position,  so  as  to  prevent  prolapse  of  irLs  as  far  as 
possible.  In  severe  pain  leeches  to  the  temple  re- 
lieve temporarily;  but  if  it  returns,  and  particularly 
if  there  is  increased  tension  or  hypopyon,  corneal 
section  is  advisable.  {See  page  567.)  If  the  hypopyon 
returns  and  the  tension  keeps  high,  iridectomy  should 
be  performed. 

In  all  forms  of  corneal  ulcer,  but  especially  where 
there  is  photophobia,  the  eyes  should  be  shaded  from 
light.  In  every  case  the  general  health  of  the  patient 
must  be  inquired  into,  and  the  diet  and  exercise 
regulated  according  to  the  indications.  Tonics  are 
often  useful,  quinine  seeming  to  be  so  specially  in 
purulent  ulceration  and  abscess  with  hypopyon.  Lead 
lotion  should  never  be  used  where  there  is  a  corneal 
abrasion,  as  we  are  apt  to  get  an  opaque,  white, 
sharply  margined,  insoluble  opacity  as  the  result. 
This  lead  deposit  can  be  removed  piecemeal  with  care, 
by  means  of  a  Beei's  knife  inserted  below  the  edge  of 
the  flake. 


Kera  titis.  569 

2.  Abscess   of  tlie    cornea.— We  get  one  or 

more  circumscriLed  yellow,  purulent  infiltrations  in 
the  corneal  substance,  with  circumcorneal  injection 
and  often  with  severe  subjective  symptoms.  Their 
occurrence  is  often  connected  with  a  low  state  of 
health,  as  from  over-lactation  or  after  an  exanthem; 
sometimes  they  are  found  with  granular  lids  or  puru- 
lent conjunctivitis.  The  abscess  tends  to  burst 
anteriorly  and  form  an  ulcer ;  exceptionally  it  opens 
posteriorly.  In  all  cases,  except  where  there  is 
trachoma  or  other  form  of  conjunctivitLs,  the  treat- 
ment should  consist  of  hot  fomentations  and  atropine. 
When  of  considerable  size,  say  2  mm.  in  diameter, 
and  in  all  cases  complicated  by  hypopyon,  paracentesis 
through  the  floor  of  the  abscess  is  indicated.  When 
conjunctivitis  is  present  cold  applications  are  best, 
with  atropine,  and  appropriate  treatment  of  the 
palpebral  conjunctiva. 

3.  Keratitis  punctata  is  the  term  usually 
applied  to  cases  where  numerous  round,  opaque, 
whitish  dots  are  found  on  Descemet's  membrane, 
generally  disposed  in  the  form  of  a  triangle  on  the 
lower  part  of  the  cornea  with  its  apex  central.  There 
is  nearly  always  iritis,  and  it  is  particularly  common 
in  sympathetic  ophthalmitis.  Sometimes  in  young 
(?)  strumous  adults  it  occurs  without  ai)parently  any 
iritis,  i.e.  without  discoloration,  contraction  of  pu[>il, 
or  posterior  synechias  ;  this  form  is  often  associated 
with  a  deep  anterior  chamber  and  increased  tension, 
and  the  iritis  present  is  not  plastic.  The  condition 
just  described  is  called  Descemet'itis  by  some,  the  term 
punctate  keratitis  being  restricted  to  cases  where 
w^hitish  punctate  infiltrations  occur  in  t^he  posterior 
part  of  the  corneal  stroma. 

Treatment. — Hot  fomentations  and  atropine  are 
useful  locally,  the  latter  not  increasing  tension  here. 
The  cases  are  usually  very  tedious.     The  patient  must 


570 


Manual  of  Surgery. 


wear  a  shade  or  dark  goggles,  and  have  constitutional 
or  other  treatment  according  to  the  j^i'obable  cause  of 
the  local  affection. 

4.  Diffuse  interstitial  keratitis  begins  in 
tlie  centre  or  near  the  edge  of  the  cornea  as  an  area 
of  slight  opacity  ;  in  the  course  of  a  few  weeks  it 
spreads  gradually  over   the  entire  cornea,  denser  at 


Fig.  121. — Thickening  of  Cornea  and  formation  of  Vessels  in  its  Stroma 
in  Interstitial  Keratitis.  Subconjunctival  tissue  thickened.  (After 
Nettleship.) 

some  parts  than  at  others.  We  find  usually  a  patchy 
light  red  (^'salmon-coloured  ")  vascularity,  commencing 
at  the  periphery  and  extending  inwards  towards  the 
centre  of  the  cornea  (Fig.  121).  There  is  circumcorneal 
congestion  and  a  varying  degree  of  photophobia  ;  iritis 
frequently  occurs.  The  attack  lasts  on  an  average 
from  six  to  twelve  months,  and  is  almost  always  bi- 
lateral, but  commonly  with  an  interval  of  a  few  weeks 
between  its  onset  in  the  two  eyes.  It  generally 
occurs  during  second  dentition,  but  it  may  exception- 
ally be  met  with  in  early  childhood  or  as  late  as 
middle  life.  The  infiltration  is  very  rarely  purulent,  but 
in  some  cases  it  is  exceedingly  severe,  causing  corneal 


Kera  Tins. 


571 


shrinking.  As  a  rule  the  opacity  clears  up  wonder- 
f\illy,  the  patient  ultimately  getting  very  good  vision. 
In  the  great  ma^jority  of  cases  we  get  a  definite  history 
of  inherited  syphilis,  and  very  commonly  we  find  other 
signs  of  the  disease  in  the  patient,  e.g.  the  character- 
istic pegged  or  notched  teeth,  scarring  at  the  angles  of 
the  month,  deafness,  etc. 

Treatment. — Locally,  atropine  drops  ;  if  there  be 
pain,  hot  fomentations  and  leeches  to  the  temples. 
Internally,  a  mild  course  of 
mercury  is  advisable,  with  iron 
if  there  be  anaemia  ;  a  pill  (or 
powder)  containing  hydrargy- 
rum cum  creta,  ferrum  redactum 
aa  gr.  j,  may  Ije  given  three  or 
four  times  daily,  the  effect  on 
the  gums  being  carefully 
watched. 

Conical  cornea  usually 
begins  shortly  after  puberty, 
and  increases  very  gradually, 
sometimes  becoming  stationary  spontaneously.  It 
is  most  common  in  females.  The  apex  of  the 
cone  corresponds  to  a  point  a  little  below  the 
centre  of  the  cornea,  and  it  often  becomes  nebulous 
in  advanced  cases.  The  condition  is  best  recog- 
nised on  looking  at  the  cornea  sideways,  but  a 
prominent  cone  is  easily  seen  in  any  position,  and 
gives  a  glistening  appearance,  as  if  there  were  a  tear 
in  the  eye  (Fig.  122).  The  myopic  astigmatism  pro- 
duced is  irregular,  and  cannot  be  corrected  by  an 
ordinary  glass,  but  vision  may  often  be  improved  by 
wearing  a  disc  with  slit  aperture,  the  exposed  corneal 
meridian  being  corrected  with  its  appropriate  concave 
lens.  When  the  cone  is  sharp-pointed  or  nebulous, 
removing  a  wedge-shaped  piece,  including  the  apex, 
produces  the  best  result. 


Fig.    122. — Conicnl  Cornea. 
(After  Mackenzie.) 


572  Manual  of  Surgery, 

Tumours  of  the  cornea  are  very  rare  as  primary 
growths,  and  it  is  generally  only  affected  in  its  super- 
ficial layei-s.  Dermoid  tumour,  epithelioma,  and  sar- 
coma are  the  most  frequent  in  occurrence. 

Injuries. — Foreign  bodies  on  or  in  the  cornea  are 
to  be  removed  with  a  spud  or  bent  needle  ;  after  this 
operation^  and  in  cases  of  simple  abrasion,  the  eye 
should  be  bandaged  until  the  epithelium  is  restored. 
Cocaine  is  very» serviceable  where  foreign  bodies  have 
to  be  picked  out,  the  only  disadvantage  from  its  use 
in  such  cases  being  that  it  renders  the  cornea  abnor- 
mally flaccid.  Ordinary  cleanly  cut  corneal  wounds 
usually  heal  quickly.  Where  'prolapse  of  iris  has 
occurred,  and  the  case  is  quite  recent,  we  may  try  the 
effect  of  eserine,  or  atropine  with  cocaine,  according 
to  its  position  (the  mydriatic  where  central,  eserine 
where  peripheral),  so  as  to  induce  its  retraction  within 
the  chamber ;  we  should  never  use  a  spatula  to  push 
back  the  prolapsed  iris.  If  the  prolapse  be  of  more 
than  a  few  hours'  standing  it  is  best  to  seize  it  with 
iris  forceps,  pull  it  free,  if  possible,  from  the  edges  of 
the  wound,  and  snip  it  off  internal  to  the  constricted 
portion.  If  it  has  existed  too  long  to  be  freed  in  this 
manner,  we  must  cut  it  off  level  with  the  cornea,  or 
we  may  enlarge  the  original  wound  and  remove  a 
larger  piece  of  iris,  inclu<]ing  its  sphincter  edge.  In 
burns  from  lime,  hot  metals,,  etc.,  our  prognosis  should 
be  guarded,  as  the  cornea  may  remain  fairly  clear  for 
some  days  after  the  injury,  and  yet  the  result  prove 
ultimately  unfavourable.  In  recent  cases  any  remain- 
ing fragment  of  metal  or  other  solid  must  be  removed, 
and  in  the  case  of  burns  with  acids  or  alkalies  the 
conjunctival  sac  is  to  be  thoroughly  washed  out  with 
a  mild  solution  of  opposite  reaction.  Ice  compresses 
should  be  applied  in  all  cases  of  severe  recent  injury, 
and  in  corneal  bums  a  drop  of  atropine  and  of  castor 
oil  are  to  be  put  inside  the  lid,  thrice  daily.     When 


Iritis.  573 

keratitis  results,  hot  fomentations,  etc.,  must  be  used 
as  recommended  above. 

Diseases  op  the  Iris. 

Iritis. — The  subjective  symptoms  of  acute  iritis 
are  pain,  photophobia,  lacrymation,  and  imjjairment  of 
vision.  The  amount  of  'pain  varies  much  in  different 
cases  and  at  different  times  ;  it  \s>  usually  worst  at  night 
and  during  an  early  stage  of  the  attack,  and  is  most  apt 
to  be  severe  in  the  arthritic  and  the  traumatic  varieties. 
The  first  symptom  of  iritis  is  often  an  itching  sensation 
down  the  side  of  the  nose,  and  tlie  pain  is  referred  not 
only  to  the  eye,  but  also  frequently  to  the  supra-orbital, 
temporal,  and  other  branches  of  the  fifth  nerve.  The 
'photophobia  and  lacrymation  are  seldom  so  severe  as  in 
corneal  affections,  and  are  worst  at  an  early  stage  of  an 
acute  attack.  The  impairment  of  vision  is  generally  due 
to  the  opacity  of  the  media  (cornea,  aqueous,  pupillary 
area  of  anterior  capsule,  or  rarely  vitreous) ;  some- 
times also  to  hypersemia  of  the  optic  disc  and  retina. 
The  local  symptoms  are  circumcomeal  congestion, 
discoloration  of  iris  and  loss  of  its  lustre,  narrowness 
of  l^upil,  slowness  of  pupillary  reaction,  and  posterior 
synechite.  The  circumcomeal  congestion  occurs  as  a 
lilac-coloured  zone,  about  two  to  four  mm.  wide ; 
sometimes  the  anterior  and  posterior  conjunctival 
vessels  are  also  congested.  Discoloration. — A  blue  or 
grey  ^ris  becomes  greenish,  and  a  brown  becomes  dark 
reddish-brown;  occasionally  the  change  of  colour  is 
only  partial.  The  discoloration,  loss  of  lustre,  narrow 
pupil,  and  sluggish  action  to  light  and  mydriatics  are 
all  due  to  congestion,  with  efiusion  of  lymph  and 
serum  into  its  substance.  A  large  amount  of  solid 
exudation  into  the  iris  often  occurs  in  syphilitic  iritis, 
sometimes  appearing  as  distinct  yellow  or  rust- 
col  011  red  nodules  on  its  anterior  surface.  Sometimes 
we  get  opacities  in  the  aqueous  humour  from  pus  or 


574 


Manual  of  Surgery. 


blood  corpuscles ;  their  presence  in  suspension  assists 
in  producing  an  apparent  discoloration  of  iris.  When 
they  form  a  deposit  in  the  anterior  chamber  we  get 
hypopyon  or  hyphsema.  A  large  hypopyon  is  usually 
found  in  cases  of  iritis  secondary  to  keratitis  or 
purulent  choroiditis.  Hyph^ema  is  commonly  the 
result  of  wound  of  the  iris,  but  sometimes  occurs  from 
R  blow,  or  during  whooping  cough.  Occasionally  we 
get  a  round  grey  gelatinous  mass  in  the  anterior  cham- 
ber from  coagulation  of  the  exudation,  looking  some- 
what like  a  dislocated 
lens.  Posterior  syne- 
chice  are  the  result  of 
an  exudation  of  lymph 
on  the  posterior  sur- 
face of  the  ii'is,  gum- 
ming it  to  the  anterior 
lens  capsule ;  they 
usually  occur  at  the 
pupillary  edge.  They 
become  readily  visible 
on  using  atropine,  the 
pupil  dilating  between  the  synechia,  which  now 
appear  as  pointed  projections  from  the  edge  of  the  iris 
(Fig.  123).  If  no  apparent  change  in  the  pupil  take  place 
on  using  atropine,  the  pupillary  edge  is  adherent  all 
round  {excluded  pupil),  or  the  entire  posterior  surface 
of  the  iris  is  adherent  {total  posterior  synechia).  When 
much  lymph  is  exuded  it  may  cover  the  entire  pupil, 
forming,  when  organised,  a  more  or  less  dense  whitish 
TCi&mhvd^rvQ  {occluded  pupil).  In  non- plastic  inflammation 
no  posterior  synechiae  are  formed.  Not  infrequently  we 
get  a  punctate  precipitate  on  Descemet's  membrane,  a 
secondary  keratitis  punctata.      {See  page  568.) 

Tlie  most  convenient  classification  of  iritis  is  an 
etiological  one,  and  we  shall  therefore  consider  at  the 
same  time  its 


.X'^^^ 


Fig.    123.— Posterior    SynechisB, 
result  of  Iritis. 


the 


iFfTis.  575 

Causes  and  varieties, — Iritis  may  arise  from 
local  injury  or  from  constitutional  disease ;  it  may 
also  be  secondary  to  other  inflammation  in  the  same 
eye,  or  sympathetic  from  wound  of  the  opposite 
eye. 

Traumatic  iritis  is  not  only  caused  by  injuries  of 
the  iris  itself,  but  may  follow  any  penetrating  wound 
of  the  eye-ball,  particularly  in  old  people  and  where 
the  lens  has  been  wounded.  Slighter  forms  of  it  often 
follow  cataract  extraction ;  sometimes  after  this 
operation  the  iritis  is  severe,  and  may  be  suppurative 
where  there  is  purulent  infiltration  of  the  corneal 
wound.  Occasionally  superficial  corneal  wounds 
and  direct  blows  on  the  eye  are  followed  by  iritis. 

The  constitutional  causes  of  iritis  are  syphilis, 
rheumatism,  gout,  and  possibly  struma.  Syphilitic 
iritis  is  acute,  and  usually  symmetrical ;  it  occurs  in 
the  secondary  stage  of  the  disease,  either  acquired  or 
congenital.  There  is  often  much  efi^usion  of  lymph,  and 
occasionally  vascular  nodules  of  it  project  from  the  sur- 
face of  the  iris  near  the  pupillary  edge;  when  large,  these 
may  suppurate  and  cause  hypopyon.  Rheumatic  iritis 
is  recurrent,  and  both  eyes  usually  sufter,  but  seldom 
both  at  once.  The  interval  between  the  relapses  may 
be  many  months.  There  is  rarely  much  lymph 
efiused,  but  the  congestion  and  pain  are  often  very 
severe.  It  sometimes  accompanies  gonorrhceal  rheu- 
matism. Gouty  iritis  resembles  the  rheumatic  in 
its  being  recurrent,  and  in  its  affecting  one  eye  at  a 
time.  It  is  sometimes  very  chronic  and  insidious, 
leading  slowly  to  much  contraction  of  pupil  and 
impairment  of  vision  without  severe  pain.  Struma 
is  said  to  be  the  cause  of  some  cases  of  slight  iritis, 
with  keratitis  punctata,  occurring  in  young  adults. 
Secondary  iritis  may  result  from  continuity  of  sti^uc- 
ture  in  inflammations  of  the  cornea  (j)articularly  when 
complicated  with  hypopyon),  ciliary  region,  or  choroid. 


576  Manual  of  Surgery. 

Sympathetic  iritis  and  its  peculiar  symptoms  will  be 
considered  later. 

Results  of  iritis. — The  adhesions  are  often 
persistent,  but  if  due  to  freshly  effused  lymph  they 
will  nearly  always,  sooner  or  later,  yield  to  atropine, 
often,  however,  leaving  permanent  dark  spots  of  uveal 
pigment  on  the  anterior  surface  of  the  lens  capsule. 
When  complete  exclusion  of  the  pupil  occurs  the  body 
of  the  iris  becomes  bulged  forward  by  the  aqueous  fluid 
between  it  and  the  lens  capsule,  so  that  the  anterior 
chamber  is  shallow,  except  just  over  the  pupil  ;  in 
such  a  condition  we  are  liable  to  get  secondary 
glaucoma.  In  old-standing  cases  of  chronic  iritis 
with  numerous  posterior  synechise,  secondary  cata- 
ractous  changes  often  occur  in  the  lens.  When  the 
pupil  is  occluded  vision  is  always  much  interfered 
with,  particularly,  of  course,  if  the  membrane  be  dense, 
and  in  such  cases  also  secondary  glaucoma  may 
follow. 

Treatment. — Perfect  rest  of  the  eyes  and  the 
ase  of  a  shade  or  dark  goggles  must  be  insisted  on  till 
the  attack  has  quite  passed  off.  Locally,  atropine 
drops  (4  gr.  to  the  ounce),  one  to  be  instilled  from 
four  to  eight  times  daily,  according  to  the  severity  of 
the  attack ;  they  are  useful  in  often  breaking  down 
synechise  already  formed,  and  in  preventing  the 
formation  of  new  adhesions,  and  they  also  diminish 
congestion  and  relieve  pain.  If  the  latter  be  very 
severe,  two  or  three  leeches  should  be  applied  to  the 
temple,  and  the  eye  bathed  frequently  with  hot 
belladonna  lotion.  A  dry  pad  of  cotton  wool  is  to 
be  worn  over  the  eye  and  removed  only  when  neces- 
sary for  local  applications.  In  syphilitic  cases  mercury 
in  some  form  should  be  given  to  slight  salivation,  and 
continued  cautiously  till  acute  symptoms  disappear. 
Salicylate  of  soda  is  worthy  of  trial  in  arthritic 
cases.     Tlie    diet    must    be    carefully    regulated.      In 


iNyURIES   OF    THE   IrIS. 


577 


severe  recurrent  iritis  that  does  not  yield  to  ordinary 
treatment,  an  iridectomy  is  sometimes  followed  by 
excellent  results.  In  cases  of  recent  iujury  where 
iritis  is  dreaded,  ice  compress  continuously  applied 
over  the  closed  lids  for  twenty -four  hours  is  valuable 
as  a  prophylactic  measure.  On  the  very  first  onset  of 
the  symptoms  of  iritis  two  or  three  leeches  to  the 
temple  will  often  cut  short  the  attack. 

Iridodoueisis,  or  tremulous  iris,  is  generally  due 
to  loss  of  its  posterior  support  from  luxation  or  absence 
of  the  lens,  or  from 
fluidity  of  the  vitreous. 
Sometimes  the  iris 
quivers  slightly  in  a 
healthy  eye,  especially 
in  myopia. 

Iiijurleis  of  the 
iris. — (1)  Foreign  bodies 
which  have  penetrated 
the  cornea  and  become 
fixed  in  the  iris  must  be 
removed,  along  with  the  portion  of  iris  implicated,  by 
iridectomy. 

(2)  Iridodialysis  {coredialysis),  or  separation  of 
the  iris  from  its  ciliary  attachment,  sometimes  results 
from  a  blow  on  the  eye,  and  is  usually  accompanied 
by  hyphaema  (Fig.  124).  "When  recent,  the  treatment 
should  consist  in  ice  compresses  for  twenty-four  hours, 
followed  by  warm  fomentations  so  as  to  favour  removal 
of  the  blood  clot. 

Tiinioiirs  of  the  iris  may  be  solid  or  cystic.  The 
solid  tumours  are  tubercular,  syphilitic,  or  sarcoma- 
tous. Where  there  is  reason  to  suspect  them  to  be 
tubercular  or  sarcomatous  the  affected  piece  of  iris  and 
the  growth  should  be  removed  ;  if  this  cannot  be  done 
effectually,  the  globe  should  be  excised.  In  syphilitic 
cases  specific  treatment  must  be  adopted.  C yds  are 
L  L— 21 


Fis 


124.— Coredialysis    following    a 
blow.     (After  Wardrop.) 


578  Manual  of  Surge r v. 

generally  the  result  of  injury,  and  should  be  removed, 
as  they  are  liable  to  lead  to  secondary  glaucoma. 

Coug^euital  auoiiialies.  —  Colohoma  usually 
occurs  below,  or  down  and  in,  appearing  as  a  gap  in  the 
iris  like  that  left  by  an  iridectomy.  It  is  due  to  im- 
perfect closure  of  the  foetal  choroidal  cleft.  Iridercemia 
(absence  of  iris)  is  a  rare  condition,  often  associated 
with  microphthalmos  or  other  congenital  ocular  defect. 
Persistent  'pupillary  membrane  is  usually  only  repre- 
sented by  traces,  which  appear  as  thin  bands  of  iris 
tissue  attached  to  the  anterior  surface  of  the  iris,  but 
not  to  the  lens  capsule. 

Diseases  of  the  Sclerotic  and  Ciliary  Region. 

Episcleritis  appears  as  a  swollen,  congested, 
discoloured  patch  of  considerable  size  in  the  ciliary 
region,  the  unaffected  part  of  the  globe  usually  re- 
maining of  normal  colour.  It  is  really  a  circum- 
scribed inflammation  of  the  sclerotic  with  effusion  into 
the  subconjunctival  tissue  over  it,  and  congestion  both 
of  the  deeper  and  of  the  conjunctival  vessels.  The 
colour  is  usually  rusty  or  purplish-red.  As  a  rule, 
the  subjective  symptoms  are  slight,  but  sometimes 
the  pain  is  severe,  and  there  is  generally  much  tender- 
ness on  pressure  over  the  affected  part.  It  is  most 
apt  to  begin  in  the  outer  ciliary  region,  but  relapses 
are  usual,  fresh  spots  being  attacked  until  often  the 
entire  ciliary  area  has  suffered.  It  rarely  occurs  in 
both  eyes  at  once,  but  the  second  eye  is  often  attacked 
later.  Its  course  is  slow,  the  swelling  reaching  its 
height  in  two  to  three  weeks,  and  then  undergoing 
slow  absorption  ;  the  middle  of  the  formerly  inflamed 
patch  generally  remains  dusky.  It  is  much  most 
common  in  adults.  Causes. — One  form,  rather 
more  sharply  limited  than  the  usual  one,  is  due  to 
tertiary  syphilis.  In  other  cases  rheumatism  and 
anaemia  seem   to   be   predisposing   causes  ;  menstrual 


CvcLiTis.  579 

disturbances  are  frequently  associated  with  it  in 
women.  Treatment. — Rest,  warm  bathing,  dilute 
yellow  oxide  of  mercury  ointment  with  atropine  (with 
massage),  and  blisters  to  the  temple  are  most  service- 
able. The  medicinal  treatment  must  be  regulated  by 
the  history  and  condition  of  each  individual  case. 

Sclero-kerato-iritis  (relapsing  cycUtis,  anterior 
sclero-choroiditis)  is  the  name  applied  to  a  disease  in 
which  a  somewhat  similar  scleral  swellinsf  to  that 
just  described  occurs,  but  here  associated  with  peri- 
pheral corneal  opacity  and  iritis.  The  swelling  is 
slight,  diffuse,  and  of  a  deep  violet  colour,  occurring 
in  one  or  more  large  patches,  coming  quite  up  to  the 
corneal  border.  The  subjective  symptoms  are  usually 
severe.  It  is  extremely  tedious,  and  relapses 
are  frequent,  causing  more  and  more  corneal  haze, 
and  thinning,  staining,  and  bulging  of  the  ciliary 
region.  It  is  most  common  in  women  about  middle 
life,  and  is  often  associated  with  a  family  history  of 
struma,  or,  according  to  some,  of  arthritic  disease. 
The  treatment  is  much  the  same  as  in  the  last  affec- 
tion, atropine  being  especially  indicated  here,  and  the 
use  of  dark  glasses.  5lercury  with  cod-liver  oil  and 
iron  are  useful.  It  is  extremely  intractable,  and, 
when  practicable,  change  to  a  warm,  dry  climate  is 
advisable. 

Cyclitis  is  rare  as  a  primary  affection,  and  would 
be  recognised  by  deep  circumcomeal  injection,  with 
tenderness  on  pressure  on  this  region,  and  by  opacities 
in  the  anterior  part  of  the  vitreous  without  visible 
iritis.  The  tension  is  often  much  reduced,  but  later 
on  the  eye  may  become  glaucomatous  from  ultimate 
implication  of  the  iris  and  posterior  synechise.  A 
chronic  relapsing  form  of  the  affection,  associated  with 
irido-choroiditis  and  keratitis  punctata,  is  occasionally 
met  with  in  young  people,  and  often  with  a  history 
of  inherited  gout.     In  the  less  severe  cases  a  good 


580  Manual  of  Surgery. 

result  is  generally  obtained,  the  best  treatment  being 
rest,  dark  glasses,  and  atropine  ;  and  internally  iron 
and  quinine,  with  a  mild  mercurial  course. 

In  trauuiatic  cyclitis  marked  pain  is  an  early 
symptom,  along  with  the  other  signs  mentioned  above. 
Tlie  rest  of  the  uveal  tract  (iris  and  choroid)  are  soon 
aftected,  and  this  form  of  inflammation  is  often  a  fore- 
runner of  sympathetic  inflammation  of  the  other  eye. 
Sometimes  the  inflammation  becomes  purulent  in 
type  {panophthahnitis),  and  in  such  cases  the  liability 
to  sympathetic  disease  seems  decidedly  less  than  in 
the  plastic  form,  though  the  early  excision  generally 
practised  in  panophthalmitis  may  possibly  account  for 
this  difference. 

Wounds  of  the  sclerotic. — There  is  generally 
simultaneous  wound  of  some  part  of  the  uveal  tract, 
and  often  of  the  retina,  with  loss  of  vitreous.  Often  we 
find  haemorrhage  into  the  anterior  chamber,  or  vitreous, 
or  both.  If  the  wound  be  quite  behind  the  ciliary 
region,  i.e.  quite  a  quarter  of  an  inch  from  the  corneal 
margin,  and  recent,  we  should  apply  an  ice  compress, 
and  trust  to  its  healing.  If  it  gape  much,  one  or  two 
fine  stitches  may  be  inserted,  but  care  should  be  taken 
not  to  embrace  the  deeper  layers  of  sclera  in  our 
suture,  as  then  the  choroid  will  almost  certainly 
be  included,  and  an  irritable  eye  with  uveitis  may  be 
left.  When  a  foreign  body  is  embedded  in  the  anterior, 
but  post-ciliary,  part  of  the  sclerotic,  it  must  be  re- 
moved, the  wound  being  enlarged  for  this  purpose  if 
necessary.  Where  the  ciliary  region  is  deeply  wounded 
stitches  should  never  be  used,  and  it  is  really  safer  in 
all  such  cases  to  excise  the  eye-ball  at  once.  If  the 
lens  have  escaped  injury,  however,  and  the  case  be 
quite  recent,  ice  compress  may  be  apjjlied  and  the  eye 
watched,  and  excision  deferred  till  there  be  evident 
signs  of  cyclitis  or  marked  sympathetic  irritation. 
Uii|>(ure  of  the  sclerotic  is  not  an  uncommon 


Sympathetic  Irritation.  581 

result  of  a  direct  blow  on  the  eye,  usually  occurring  a 
little  outside,  and  concentric  with,  the  corneal  margin. 
The  rent  is  generallyiarge  and  involves  all  the  tunics,  we 
then  may  get  escape  of  the  lens  and  part  of  the  vitreous, 
there  is  blood  in  both  aqueous  and  vitreous  chambei-s, 
the  eye  is  soft,  and  vision  is  greatly  reduced.  The 
conjunctiva  is  the  tunic  most  likely  to  remain  unrup- 
tured, and  then  the  lens  may  pass  through  the  scleral 
rent  and  remain  under  the  conjunctiva  as  a  round, 
translucent  tumour.  In  very  severe  cases  of  rupture 
immediate  excision  is  best.  In  less  severe  cases,  and 
especially  when  the  conjunctiva  has  escaped  untorn, 
we  should  apply  ice  compress  and  wait  till  the  absorp- 
tion of  blood  enables  us  to  judge  of  the  probable  future 
usefulness  of  the  eye.  If  it  be  decided  to  retain  it,  a 
subconjunctival  dislocation  of  lens  should  be  left  until 
the  scleral  rent  has  healed,  when  it  can  easily  be 
removed. 

Primary  tumours  of  the  sclerotic  are  exceed- 
ingly rare  ;  sarcoma  and  fibroma  have  been  observed. 
It  is  often  secondarily  affected  in  the  case  of  morbid 
growths  of  the  choroid  or  retina. 

Sympathetic  Affections  of  the  Eye. 

The  condition  most  liable  to  excite  sympathetic 
disease  is  a  plastic  inflammation  of  the  uveal  tract 
(iris,  ciliary  region,  choroid),  usually  the  result  of  a 
wound  involving  the  ciliary  region.  The  eye  injured 
or  first  inflamed  is  called  the  "  exciting,"  the  other  the 
"sympathising"  eye. 

Sympathetic  irritation. — The  common  symp- 
toms are  lacrymation,  photophobia,  and  occasionally 
dimness  of  vision  in  the  sympathising  eye.  It  flushes 
on  exposure  to  a  bright  light,  especially  if  the  exciting 
eye  be  also  exposed  or  otherwise  irritated.  Some- 
times pain  is  felt  in  the  forehead  or  shooting  across 
the    root    of    the    nose.     The  occasional  dimness   is 


582  Manual  of  Surgery, 

usually  mainly  due  to  a  relaxation  of  the  ciliary 
muscle  rendering  accommodation  impossible,  or  some- 
times possibly  to  a  condition  of  spasm  rendering  dis- 
tant objects  indistinct.  In  such  cases  the  pupil  will 
be  found  to  react  well  to  light,  but  to  be  in  a  constant 
state  of  oscillation.  Sometimes  there  seems  to  be  a 
true  temporary  blindness,  the  nature  of  which  is 
doubtful. 

Treatment. — If  the  exciting  eye  be  lost  or  mani- 
festly a  dangerous  one,  it  must  be  excised  without 
delay.  If,  however,  it  be  uninflamed,  its  vision  good, 
and  the  wound  not  such  as  is  likely  to  lead  to 
sympathetic  inflammation,  the  patient  should  be  kept 
at  rest,  dark  goggles  worn,  and  the  condition  watched 
for  a  few  days.  If  the  irritation  persist  or  increase, 
it  is  advisable  to  excise,  but  even  after  excision  the 
symptoms  may  not  cease  for  a  considerable  time. 

Syiiipatlietic  iiillaiiiinatioii  ueually  sets  in  a 
month  or  two  after  the  injury,  but  it  may  appear  as 
early  as  two  weeks,  or  may  be  delayed  for  many  years. 
It  always  attacks  both  eyes,  but  not  necessarily  with 
like  severity.  One  of  the  earliest  and  most  constant 
signs  is  the  occurrence  of  keratitis  punctata.  In 
severe  cases  the  iiitic  adhesions  are  rapidly  formed, 
extensive  and  firm,  and  the  iris  itself  is  much  thickened, 
with  numerous  large  blood-vessels  visible  on  its  dulled 
surface.  Eventually  we  get  occluded  pupil,  increased 
tension,  and  secondary  cataract.  In  the  worst  cases 
ciliary  staphylomata  form,  and  the  globe  finally 
shrinks.  In  the  milder  cases  no  synechise  are  formed, 
or  they  give  way  readily  to  atropine. 

Treatment  is  too  frequently  of  little  avail  after 
sympathetic  ophthalmitis  has  begun.  The  exciting 
eye,  if  quite  blind  or  practically  useless,  must  be 
excised  at  once.  If  there  be  any  hope  of  useful  vision 
in  it,  however,  it  should  be  retained,  as  its  removal 
wiU  now  do  little  or  no  good  to  the  other,  and  it  may 


Cataract.  583 

eventually  be  the  better  eye  of  the  two.  The  sym- 
pathising eye,  and  the  exciting  eye  if  retained,  must 
be  covered  with  a  black  bandage  and  treated  with 
atropine,  leeching  or  blistering  to  the  temple,  and 
perfect  rest  in  a  dark  room.  In  moderately  severe 
cases,  when  the  eye  has  become  perfectly  quiet  (always 
at  least  a  year  after  the  beginning  of  the  inflamma- 
tion), an  operation  may  restore  some  vision.  Our 
great  aim,  however,  must  be  to  prevent  this  form  of 
inflammation  by  early  excision  of  lost  dangerous  eyes, 
whether  blind  from  injury,  or  from  past  inflammation 
in  which  the  iris  or  ciliary  region  has  participated. 
We  have  already  mentioned  cases  of  injury  where 
excision  is  advisable.     {See  also  page  580.) 

Diseases  of  the  Lens. 

Cataract,  or  opacity  of  the  crystalline  lens,  may 
occur  at  any  age,  and  may  be  partial  or  complete.  An 
opacity  in  this  situation  looks  white  or  light  grey  by 
reflected  light  (e.g.  on  focal  illumination),  and  black 
by  transmitted  light,  as  when  the  eye  is  illuminated 
by  the  ophthalmoscopic  mirror.  Cataract  is  said  to  be 
prima7'i/  when  it  arises  apparently  independently  of 
any  other  ocular  inflammation,  and  secondary  when  it 
follows  some  local  disease.  The  former  is  nearly 
always  symmetrical,  the  latter  may  or  may  not  be  so. 
In  advanced  life  a  greyish  reflex  is  always  obtained 
from  the  pupil  in  consequence  of  the  normal  lenticular 
changes,  and  this  is  sometimes  mistaken  for  cataract, 
but  transmitted  light  shows  no  loss  of  transparency. 

Varieties  and  diag^nosis. — Senile  cataract  is 
the  most  common  form,  and  seldom  occurs  before  fifty 
years  of  age.  It  may  begin  in  the  nucleus  or  cortex. 
Nuclear  cataract  appears  as  a  central  amber-coloured 
haze.  The  cortical  variety  generally  at  first  presents 
the  appearance  of  strite,  often  only  visible  after 
dilating  the  pupiL     These  striae  gradually  increase  in 


5S4  Manual  of  Surgery. 

number  and  breadth,  the  nucleus  gets  hazy,  and  ulti- 
mately the  whole  lens  becomes  opaque  {mature  cataract). 
Occasionally  we  simply  find  numerous  minute  dots  of 
opacity  in  the  cortex,  best  seen  by  direct  ophthalmo- 
scopic examination  with  a  strong  convex  lens  behind  the 
mirror  ;  such  cataracts  are  exceedingly  slow  in  progress. 
The  time  necessary  for  maturity  varies  in  different 
individuals,  but  the  average  time  taken  by  the  usual 
senile  cataract  is  from  two  to  four  years  from  the  first 
observed  impairment  of  vision.  In  a  cataract  just 
ripe  for  removal,  the  opacity  is  found  on  oblique 
illumination  to  be  quite  up  to  the  anterior  capsule,  or 
on  a  level  ^vith  the  pupillary  edge  of  the  iris,  and  the 
lens  has  frequently  a  spermaceti-like  lustre.  It  is 
always  symmetrical,  but  one  eye  is  generally  in  advance 
of  the  other.  If  not  extracted  it  usually  undergoes 
further  degenerative  changes,  often  becoming  hard 
and  calcareous  ;  sometimes  the  cortex  liquefies,  while 
the  nucleus  remains  hard  [Morgagnian  cataract). 

Lamellar  catarojct  is  either  congenital  or  forms  in 
early  infantile  life,  and  is  generally  associated  with 
the  occurrence  of  convulsions.  The  permanent  teeth, 
especially  the  incisors,  canines,  and  first  molars,  often 
show  deficiency  of  enamel  in  patients  with  this  affec- 
tion. The  opacity  is  seldom  very  dense,  and  affects  an 
intermediate  zone  of  the  lens,  the  nucleus  and  peri- 
phery remaining  clear.  On  dilating  the  pupil  artifi- 
cially we  find  that  the  margin  of  the  lens  is  clear,  and 
that  there  is  also  a  layer  of  transparent  lens  substance 
anterior  to  the  opaque  area.  The  opacity  itself  is 
round,  with  occasionally  sharp  opaque  spicules  project- 
ing radially  from  its  margin.  Its  size  varies  in 
different  cases,  but  is  nearly  always  similar  in  the  two 
eyes  of  the  same  patient,  and  shows  little  or  no 
tendency  to  increase. 

Congenital  cataract  may  present  different  forms  of 
opacity,  but  it  usually  involves  the  whole  lens,  and  is 


Cataract.  585 

almost  always  symmetrical  in  the  two  eyes.  There  is 
frequently  nystagmus. 

Pyramidal  cataract  is  always  the  result  of  ocular 
inflammation  in  early  life,  and  usually  of  perforating 
corneal  ulcer  from  ophthalmia  neonatorum.  It  appears 
as  a  small,  sharply  defined,  dense  white  opacity  at  tlie 
anterior  pole  of  the  lens,  sometimes  projecting  forwards 
towards  the  cornea  in  the  form  of  a  small  pyramid 
with  its  base  slightly  embedded  in  the  lens  substance. 
Once  developed  it  does  not  increase  in  size. 

Posterior  polar  cataract,  as  the  name  implies,  is  an 
opacity  at  the  middle  of  the  posterior  surface  of  the 
lens.  It  is  not  sharply  limited,  but  usually  thins  out 
irregularly  from  a  denser  centre ;  it  is  not  stationary. 
By  focal  illumination  it  is  generally  of  a  yellowish 
colour.  It  is  often  due  to  disease  of  the  vitreous 
dependent  on  choroidal  inflammation. 

Diabetic  cataract  is  usually  cortical  at  first,  and 
when  mature  presents  much  the  appearance  of  an 
ordinary  senile  cataract,  but  with  the  spermaceti 
lustre  very  distinct.  The  age  of  the  patient  often 
leads  us  to  suspect  glycosuria  in  such  cases.  When 
occurring  early  in  life  the  diabetic  form  is  soft,  instead 
of  being  hard  like  the  senile  cataract,  and  reaches 
maturity  very  quickly,  often  in  a  few  months  from  its 
first  detection. 

Subjective  symptoins.— There  is  visual  failure 
where  the  opacity  is  at  or  near  the  axis  of  the  lens. 
As  the  cataract  spreads  and  becomes  denser,  the  sight 
fails  more  and  more,  until  the  patient,  with  his  back 
to  the  light,  can  barely  count  fingers  at  a  few  inches, 
or  only  distinguish  the  hand  moving  before  his  eye. 
Many  subjects  of  cataract,  especially  where  the  nucleus 
is  principally  afiected,  see  best  in  a  dull  light,  as  the 
large  pupil  then  allows  the  rays  to  pass  through  the 
clearer  peripheral  parts  of  the  lens. 

Caiisos — The  manner  of  production  of  an  ordinary 


586  Manual  of  Surgery. 

primary  cataract  is  not  understood.  It  is  often 
found  associated  with  general  senile  changes,  with 
arterial  disease,  gout,  and  especially  with  glycosuria. 
When  cataract  results  from  some  local  disease,  such 
as  choroiditis,  old  iritis,  glaucoma,  detached  retina, 
intra-ocular  tumour,  etc.,  it  is  called  "secondary,"  and 
is  then  frequently  uniocular.  Traumatic  cataract  will 
be  considered  later. 

TreatHient.— We  can  often  improve  vision  con- 
siderably in  the  early  stages  of  senile  cataract  by  keep- 
ing the  pupil  under  the  influence  of  a  weak  mydriatic* 
In  some  slight  cases  of  lamellar  cataract  no  operation 
is  necessary,  the  patient  seeing  sufficiently  well  for  all 
practical  purposes.  Before  attempting  any  operation 
we  should  examine  the  condition  of  the  eye  and  of 
the  patient  carefully.  Thus,  if  the  eye  be  perfectly 
blind,  it  is  needless  to  remove  the  cataract.  Again, 
if  the  projection  be  bad,  if  there  be  traces  of  old  iritis, 
if  the  cornea  be  nebulous,  or  if  the  patient  be  suflfering 
from  glycosuria  or  other  form  of  malnutrition,  the 
prognosis  must  be  guarded  accordingly,  and  special 
care  taken  in  the  operation  and  in  the  after-treatment. 
To  test  the  projection,  light  is  thrown  into  the  eye  by 
the  ophthalmoscopic  mirror  from  different  points  of 
the  visual  area  ;  if  the  patient  can  always  indicate 
truly  the  direction  from  which  it  comes,  his  projection 
is  good.  If  there  be  lacrymal  obstruction  or  conjunc- 
tivitis, operation  must  be  deferred  till  the  condition  is 
cured.  The  oi:)erative  treatment  indicated  varies 
according  to  the  consistence  of  the  cataract;  or,  which  is 
practically  the  same  thing,  the  age  of  the  patient. 
Under  thirty-five  years  of  age  the  cataract  is  always 
soft,  and  the  best  means  of  removing  it  are  :  (1)  discis- 
eion,  the  lens  being  needled  and  allowed  gradually  to 
become  absorbed  in  the  aqueous;  and  (2)  removal  by 

*  Atrop.  sulpbat.  gr.  i ;    zinci  sulph.  gr.    ^ ;   aq.    destill.    ^j. 
One  di-op  eveiy  second  day. 


Cataract.  587 

auction  or  curette,  generally  after  a  previous  breaking 
up  of  the  lens  substance  by  needling.  After  any  such 
operation,  ice  compress  must  be  applied  for  twenty- 
four  hours,  and  the  eye  kept  under  atropine  until  all 
redness  has  disappeared.  In  the  case  of  hard  cataract, 
(after  thirty-five  years  of  age)  the  lens  should  be 
extracted  entire.  The  modified  Graefe  incision  with  a 
long  narrow  knife  is  that  usually  now  adopted,  the 
puncture  and  counter-puncture  being  made  at  the 
apparent  sclero-corneal  junction,  about  the  level  of 
the  upper  border  of  the  undilated  pupil,  and  the  centre 
of  the  incision  coming  just  within  the  apparent  upper 
corneal  margin.  An  iridectomy  is  then  performed  (if 
not  done  as  a  preliminary  step  at  least  six  weeks  pre- 
viously), the  anterior  capsule  opened  freely,  and  the 
opaque  lens  extracted  through  the  corneal  wound  by 
pressing  with  a  curette  against  the  lower  part  of  the 
cornea.  All  cortical  matter  must  be  carefully  removed. 
After  the  operation  both  eyes  are  covered  with  dry 
cotton  wool  and  an  appropriate  bandage,  the  patient 
being  kept  in  a  darkened  room,  and  the  eyes  bathed 
gently  every  morning  and  evening  for  the  first  week. 
On  the  earliest  symptoms  of  iritis  leeches  must  bo 
applied  to  the  temple,  and  atropine  drops  put  into  the 
eye.  Should  the  edges  of  the  wound  become  infiltrated 
with  pus,  hot  fomentations  are  advisable,  and  eserine 
drops  six  times  daily,  or  powdered  iodoform  dusted 
into  the  eye  twice  daily.  Should  panophthalmitis 
occur,  it  is  better  to  excise  the  eye  early,  as  thus  much 
needless  pain  is  avoided.  A  bandage  should  be  used 
over  the  eye  even  in  favourable  cases  for  at  least  a 
fortnight,  and  both  eyes  carefully  shaded  from  light. 
After  a  couple  of  months  the  eye  may  be  tested  for 
glasses,  +10D  being  about  the  average  lens  required 
for  distance,  and  -}-14D  for  close  work.  Should  the 
distant  vision  be  unsatisfactory,  the  pupil  must  be 
examined    by    focal    illumination,    as   fi-equently   an 


5SS  Manual  of  Surcerv. 

opaque  membrane  is  found  covering  it.  If  present 
this  membrane  must  be  torn  through  with  one  or  two 
needles,  so  as  to  leave  a  clear  aperture  corresponding 
to  the  centre  of  the  cornea.  After  this  secondary- 
operation  ice  and  atropine  must  be  used,  and  the  eyes 
kept  shaded  until  all  irritation  and  injection  subside. 
For  all  cataract  operations  cocaine  is  most  serviceable, 
but  it  must  be  remembered  in  performing  iridectomy 
under  its  influence  that  it  does  not  fully  deaden  the 
sensibility  of  the  iris."*" 

Injuries. — (1)  Traumatic  cataract  is  the  result  of 
any  injury  by  which  the  lens  capsule  is  opened.  It 
may  follow  a  penetrating  wound  of  the  globe,  or  may 
simply  be  due  to  a  direct  blow  rupturing  the  lens 
capsule.  In  recent  cases  ice  compress  and  atropine 
drops  must  be  used,  A  small  piece  of  metal  is  some- 
times embedded  in  the  lens,  and  may  be  removed  by 
the  electro-mamet.  Should  the  lens  swell  so  as  to 
produce  increased  tension,  it  must  be  removed  by 
curette  or  suction.  In  young  patients  the  cataract 
sometimes  undergoes  slow  spontaneous  absorption,  as 
after  the  operation  of  discision.  If  severe  iritis 
supervene,  in  cases  due  to  punctured  wound,  early 
excision  is  advisable,  as  the  eye  will  never  be  a  service- 
able one,  and  is  very  likely  to  set  up  sympathetic 
inflammation.  (2)  Dislocation  of  the  lens  is  occasion- 
ally the  result  of  a  direct  blow  on  the  eye-ball.  It  is 
generally  still  enclosed  in  its  capsule,  and  is  commonly 
displaced  downwards,  its  upper  edge  being  still  visible 
through  the  dilated  pupil.  It  ultimately  often 
becomes  cataractous,  and  sometimes  causes  glaucoma. 
Occasionally  the  dislocated  lens  lies  in  the  anterior 
chamber.     From  either  situation  it  may  be  removed 

*  Solutions  of  all  alkaloids  used  after  any  perforating  wound  of 
the  eye-ball  should  be  freshly  prepared, as  the  fungoid  growths  which 
Boon  form  in  them  seem  sometimes  to  have  a  most  prejudicial 
effect. 


Optic  Neuritis.  589 

by  the  spoon  through  a  large  peripheral  corneal  inci- 
sion, but  the  operation  is  one  of  great  delicacy  and 
liable  to  be  accompanied  by  much  loss  of  vitreous. 

Coug^enital  abnormalities.— Con^e/iz^a^  cata- 
ract has  been  already  alluded  to.  Occasionally  we  find 
partial  congenital  dislocation  of  the  lens,  usually  in  both 
eyes.  Appropriate  glasses  ai-e  often  serviceable  in 
such  cases. 

Diseases  of  the  Optic  Nerve. 

Developmentally  and  structurally  the  optic  nerve 
is  unlike  ordinary  cerebro-spinal  nerves,  and  is  to  be 
regarded  as  a  direct  prolongation  of  the  brain.  It  is 
peculiarly  liable  to  suffer  in  affections  of  the  central 
nervous  system,  in  certain  general  diseases,  and  in 
some  forms  of  chronic  poisoning. 

Inflammatioii  of  tiie  optic  nerve.— P«^Ao- 
logy.  The  intra-ocular  end  of  the  hqyvq  {^^ papiVa") 
is  the  part  most  commonly  inflamed,  and  to  this  con- 
dition the  term  '■^ papillitis  "  is  conveniently  applied. 
When  the  inflammation  first  attacks  the  nerve  trunk 
behind  the  eye-ball,  we  speak  of  it  as  a  ^^post-ocular 
neuritis,'^  The  expression,  ^^  optic  neuritis,^'  should  be 
retained  as  a  general  term  for  inflammation  of  any 
part  of  the  nerve.  Optic  neuritis  may  be  acute  or 
chronic,  may  occur  at  any  point  in  the  course  of  the 
nerve,  may  affect  the  whole  thickness  or  only  a  part 
of  it,  and  may  or  may  not  lead  to  permanent  atrojjhy. 
Where  the  periphery  of  the  nerve  is  mainly  involved, 
we  call  the  condition  ^^  perineuritis  ;  ^^  where  the  in- 
flammation attacks  the  central  part  of  the  nerve  we 
speak  of  it  as  "  axial  neuritis."  Usually  both  nerves 
are  affected,  though  not  necessarily  to  the  same  de- 
gree nor  consentaneously ;  unilateral  optic  neuritis  is 
generally  dependent  on  a  local  cause,  such  as  orbital 
cellulitis.  In  the  early  stage  of  a  papillitis,  the  con- 
nective tissue  is   unaffected  j  and  if  the  inflammation 


590  Manual  of  Surgery. 

proceed  no  further,  we  may  finally  get  a  healthy  disc 
and  retention  of  normal  vision.  Usually,  however, 
we  ultimately  get  interstitial  changes. 

Symptoms. — There  is  usually  no  ocular  pain, 
and  there  may  not  even  be  loss  of  sight  for  some  time. 
In  exceptional  cases,  indeed,  papillitis  may  run  its 
course  and  disappear  again  without  there  being  any 
impairment  of  vision,  but  usually  sight  fails  gradually. 
The  manner  of  the  failure  varies  according  to  the  kind 
of  the  neuritis.  In  ordinary  papillitis  we  have  a  pro- 
gressive loss  of  central  vision  along  with  a  peripheral 
diminution  of  the  visual  field.  In  some  cases  of  post- 
ocular  neuritis,  in  the  axial  form  for  example,  we 
have  the  central  vision  alone  first  impaired,  the 
peripheral  field  remaining  perfect ;  in  such  cases  the 
loss  of  colour  vision  is  characteristic,  the  power  of 
distinguishing  red  and  green,  in  a  small  central  area, 
being  often  lost  at  the  very  commencement  of  the 
affection. 

Ophthalmoscopic  appearances. — We  must  exercise 
much  caution  in  diagnosing  positively  the  slighter 
departures  from  the  normal  vascularity  of  the  papilla, 
and  we  must  invariably  examine  both  eyes.  In  simple 
passive  congestion  of  the  papilla,  it  is  redder  than 
normal,  and  the  veins  are  somewhat  dilated,  but  there 
is  no  swelling,  and  though  its  margin  is  wanting  in 
definition,  it  is  not  actually  obscured.  Between  such 
a  condition  and  a  fully  developed  papillitis  or  "  choked 
disc,"  there  are  many  gradations,  which  may  siraply 
be  stages  in  the  development  of  a  high  degree  of 
papillitis,  or  any  one  of  them  may  be  the  final  condi- 
tion where  the  inflammation  is  of  less  severity.  In 
advanced  papillitis  the  changes  are  unmistakable ;  we 
find  swelling  of  the  papilla,  with  obscuration  of  its 
margin,  loss  of  translucency,  increased  vascularity, 
and  obliteration  of  the  physiological  cupping. 
Numerous  straight  vessels  radiate  from  it  on  every 


Optic  Neuritis.  591 

side,  coursing  over  its  obscured  edge,  and  small  haemor- 
rhages often  occur  on  or  near  it.  The  veins  are  dis- 
tended, dark  and  tortuous,  and  the  arteries  usually  some- 
what narrowed  ;  both  sets  of  vessels,  but  especially  the 
arteries,  are  often  hidden  on  or  near  the  disc.  Smooth, 
opaque,  whitish  spots  occur  on  the  papilla  or  on  the 
surface  of  the  adjacent  retina,  concealing  completely 
what  they  cover,  and  there  are  often  large  areas  of 
cloudiness  in  the  retina.  As  the  papillitis  subsides, 
the  redness  and  swelling  diminish,  and  the  disc  margin 
again  comes  into  view.  The  disc  is  first  opaque  and 
"  woolly  "  looking,  but  gradually  becomes  smoother, 
and  is  ultimately  (stage  of  atrophy)  of  a  white  colour, 
with  concealment  of  the  lamina  cribrosa  ;  around  it 
there  is  often  a  pale  zone  from  changes  in  the  retinal 
pigment ;  the  vessels  are  all  much  narrowed,  and  are 
often  bordered  by  opaque  white  lines. 

Causes. — {a)  A  large  majority  of  cases:of  papillitis 
are  due  to  intracranial  disease  ;  e.g.  tumours,  menin- 
gitis, cerebral  abscess,  internal  hydrocephalus,  aneu- 
rism of  internal  carotid.  Injuries  to  the  head  may 
cause  optic  neuritis  either  through  meningitis,  efiiision 
of  blood  (within  the  skull  or  within  the  nerve  sheath), 
hernia  cerebri,  or  possibly  through  a  laceration  of 
the  brain. 

{h)  We  are  liable  to  get  optic  neuritis  (usually  one- 
sided) in  many  orbital  affections  ;  e.g.  tumours,  cellu- 
litis, periostitis,  etc.  In  the  case  of  orbital  tumour 
there  is  generally  protrusion  of  the  eye-ball. 

(c)  Papillitis  has  been  observed  in  association  with 
acute  myelitis,  and  in  cases  of  injury  to,  and  caries  of, 
the  cervical  spine. 

(d)  In  general  diseases,  e.g.  progressive  pernicious 
ana3mia  and  Bright's  disease,  but  in  cases  of  the  latter 
we  usually  have  a  characteristic  retinitis  in  addition. 
Acqvvi'ed  syphilis  may  cause  optic  neuritis  either 
through    meningitis    or    from    a    gummatous  growth, 


592  Manual  of  Surgery. 

which  latter  may  be  within  the  skull,  or  at  the  optic 
foramen,  or  on  the  nerve  trunk,  the  neuritis  being 
generally  one-sided  when  in  either  of  the  two  last 
situations.  In  diabetes  mellitus  we  get  an  axial 
neuritis,  and  probably  the  same  limited  inflammation 
is  caused  by  chronic  poisoning  by  lead,  alcohol,  tobacco, 
and  bisulphide  of  carbon 

(e)  Sometimes  optic  neuritis  is  simply  an  extension 
of  inflammation  from  a  neighbouring  ocular  tissue. 

The  prog-iiosis  must  always  be  guarded  as  to  the 
flnal  condition  of  vision,  and  depends  more  on  the 
cause  than  on  the  intensity  of  the  papillitis  obse>red. 
It  is  relatively  more  favourable  where  the  cause  is 
removable  or  amenable  to  remedies.  We  may  have 
a  papillitis  with  good  vision,  leading  ultimately  to 
complete  atrophy  and  blindness,  while  again  we  may 
have  a  papillitis  with  the  barest  perception  of  light, 
followed  by  almost  perfect  recovery. 

Ti'eatnfieiit. — Where  not  contra-indicated,  mer- 
cury and  iodide  of  potassium  should  be  employed  as  a 
matter  of  routine,  the  latter  being  given  in  full  doses. 
Perfect  rest  must  be  insisted  upon,  and  the  cause  i» 
to  be  treated  by  appropriate  remedies  when  possible, 
or  to  be  removed  altogether  in  the  case  of  exposure  to 
poisons.  Locally,  dry  or  wet  cupping,  or  blisters  to 
the  temple,  may  be  tried,  and  ice  to  the  forehead  has 
been  recommended  in  an  early  stage. 

Atrophy  of  the  optic  nerve. — Pathology.  In 
all  cases  of  atrophy  the  nerve  is  ultimately  affected  in 
its  entire  length.  In  all  true  cases  the  nervous  ele- 
ments  are  involved,  and  there  is  a  corresponding  loss 
of  function.  In  the  post-neuritic  atrophic  process  the 
nerve  fibres  finally  either  break  down  and  are  re- 
moved, or  undergo  grey  degeneration  ;  in  the  former 
case  the  diameter  of  the  nerve  is  much  reduced  from 
contraction  of  the  hypertrophied  fibrous  tissue.  In 
nmple    atrophy    there    is    seldom    much    increase    of 


Atrophy  of  Optic  Nerve.  593 

connective  tissue,  but  the  nerve  fibres  lose  their  me- 
dullary sheath  by  a  process  of  granular  fatty  degenera- 
tion, while  the  axis  cylinders  are  usually  retained,  but 
converted  into  fine  indistinct  fibrils  ;  there  is  conse- 
quently little  change  in  the  size  of  the  nerve.  This 
"  grey  degeneration,"  as  it  is  termed,  may  be  difftise, 
affecting  the  whole  nerve  uniformly,  or  insular  and 
varying  much  in  extent  in  different  sections.  In  most 
cases  of  atrophy  both  nerves  are  affected,  though  one 
may  be  considerably  in  advance  of  the  other. 

Causes. — All  cases  may  be  divided  broadly  into 
hijiammatory  and  non-inflammatory  or  simple.  (1) 
Those  due  to  inflammation  are  traceable  either  to  a 
papillitis,  a  post-ocular  neuritis,  or  an  inflammation  of 
the  choroid  or  retina.  (2)  Simple  atrophy  may  be 
primary  or  secondary.  In  the  primary  form  we  get 
visible  atrophic  changes  occurring  consentaneously 
with  gradual  failure  of  vision,  often  in  association  with 
disease  of  the  central  nervous  system  (locomotor 
ataxy,  etc.).  The  more  immediate  cause  of  this  form 
seems  to  be  severe  bodily  fatigue,  anxiety,  exhausting 
brain  work,  sexual  excess,  etc.  In  the  secondary  form 
of  atrophy  the  loss  of  vision  precedes  the  visible  atro- 
phic changes.  This  occurs  in  all  cases  where  inter- 
rupted conductivity  in  one  part  of  the  nerve  leads  to 
subsequent  atrophy  in  the  remainder,  as  where  the 
nerve  has  been  cut  across,  or  torn  through,  or  pressed 
upon  (by  tumours,  foreign  bodies,  etc.),  or  has  had  its 
blood  supply  interrupted  (as  from  embolism).  Syphilis 
may  induce  either  a  post-inflammatory  atrophy  or  a 
secondary  one  (as  from  pressure  of  a  gumma),  and  a 
specific  history  is  also  common  in  cases  of  simple  grey 
degeneration. 

Symptoms. — The  failure  of  vision  in  post-neu- 
ritic  cases  has  been  already  described.  {See  page  590.) 
In  atrophy  from  choroiditis  and  retinitis  the  failure  is 
usually  gradual,  central  vision  often  remaining  fairly 

M   M— 21 


594  Manual  of  Surgery. 

acute  while  the  rest  of  the  field  has  become  amblyopia 
In  the  secondary  form  of  simple  atrophy  vision  often 
fails  suddenly.  In  primary  atrophy  the  loss  of  vision 
is  slow  and  continuous,  there  being  both  central 
failure  and  contraction  of  field.  Affection  of  the 
colour  sense  is  almost  constant,  green  being  generally 
first  confused,  while  later  perception  fails  for  red, 
blue,  and  lastly  yellow.  The  pupils  are  generally 
wide  in  post^papillitic  atrophy,  small  in  spinal  cases, 
and  often  of  medium  size  in  other  forms. 

Ophthalmoscopic  appearances. — The  colour  of  the 
atrophied  disc  is  white,  grey,  or  of  a  blueish  or 
greenish  tint.  The  disc  is  often  excavated  quite 
up  to  the  margin  all  round,  but  never  deeply, 
and  the  slope  is  gradual.  The  lamina  cribrosa  may  or 
may  not  be  visible.  The  edge  of  the  disc  is  usually 
well  defined.  The  central  blood-vessels  are  in  some 
cases  much  diminished  in  size,  in  others  only  slightly 
if  at  all.  In  the  post-papillitic  form  the  disc  margin 
is  often  irregular-looking  from  loss  of  pigment  due  to 
choroido-retinal  changes ;  the  central  vessels  are  re- 
duced in  size,  and  frequeutly  bordered  by  opaque 
white  lines  ;  the  excavation  is  absent  or  slight,  and 
the  lamina  cribrosa  is  invisible.  In  atrophy  from 
choroido-retinal  disease  the  disc  has  usually  a  peculiar 
opaque,  yellowish-red,  "waxy"  look,  and  the  retinal 
vessels  are  greatly  diminished  in  size,  and  sometimes 
in  number.  In  the  partial  atrophy  from  axial  neur- 
itis the  pallor  is  confined  to  the  temporal  half  of  the 
disc. 

The  prognosis  is  always  unfavourable,  but  is 
relatively  less  so  where  the  cause  is  removable  or  may 
pass  away  spontaneously.  In  some  of  the  posi- 
papillitic  cases  considerable  improvement  takes  place 
if  the  sclerosing  process  do  not  lead  to  much  pressure 
on  such  nerve  fibres  as  have  escaped  destruction  by  the 
inflammation.     In  marked  contraction  of  the  visual 


Injuries  of  Optic  Nerve.  595 

field,  and  in  cases  of  long-standing  amblyopia,  little 
Of  no  improvement  is  to  be  expected.  In  cases  of 
primary  atrophy,  almost  complete  blindness  generally 
occurs  in  from  one  to  three  years. 

Treatment. — Where  the  atrophy  is  dependent 
on  some  general  condition  or  toxic  influence,  the 
treatment  must  be  regulated  accordingly.  Nervine 
tonics,  such  as  strychnia,  are  said  to  be  occasionally 
useful.  Where  the  atrophic  process  has  not  gone  too 
far,  the  continuous  current  is  sometimes  beneficial. 
One  pole  should  be  applied  over  the  closed  eyelids  and 
the  other  over  the  supra-orbital  nerve,  the  current 
being  broken  frequently  and  the  poles  transposed. 
The  smallest  number  of  cells  which  will  give  the 
physiological  light-flash  on  making  and  breaking  the 
circuit  should  be  employed  ;  the  whole  sitting  should 
last  about  five  minutes,  and  be  repeated  daily  for  at 
least  a  month.  If  no  improvement  take  place  during 
this  time,  either  in  central  acuity  or  in  visual  field, 
galvanism  may  be  abandoned  as  useless.  If  any 
marked  benefit  result,  the  current  should  continue  to 
be  employed  at  longer  and  longer  intervals,  as  the 
condition  may  indicate.  The  patient  is  quite  capable 
of  carrying  out  the  treatment  for  himself  after  having 
once  been  properly  instructed, 

lujiu'ies. — The  optic  nerve  may  be  injured  by  a 
blow,  stab,  gun-shot  wound  or  fracture  of  the  sphenoid 
bone.  A  severe  blow  on  the  side  of  the  eye-ball  may 
cause  rupture  of  the  nerve  ■  at  its  entrance  into  the 
globe.  A  stab  or  thrust  into  the  orbit  may  cut  or 
tear  the  nerve,  or  cause  an  extravasation  of  blood 
within  its  sheath,  or  may  sever  the  central  vessels 
outside  its  tinink.  A  foreign  body  penetrating  deeply 
may  produce  fracture  of  the  orbital  walls  or  of  the 
clinoid  process  of  the  sphenoid  bone,  thus  leading  to 
injury  of  the  nerve.  Gun-shot  wounds  may  implicate 
either  the  orbital  or  intracranial  part  of  the  nerve, 


596  Manual  of  Surgery. 

and  pellets  or  metallic  fragments  may  penetrate  the 
globe  and  become  embedded  in  the  papilla.  Fracture 
of  the  base  of  the  skull  sometimes  causes  injury  to  the 
nerve  at  the  optic  foramen,  or  behind  it  if  the  clinoid 
process  be  displaced.  Any  severe  injury  to  the  nerve 
usually  occasions  sudden  complete  blindness  of  the 
corresponding  eye.  If  the  solution  of  continuity  be 
incomplete,  or  if  the  nerve  be  simply  bruised,  we  may 
get  partial  or  complete  restoration  of  vision,  but 
secondary  changes  often  occur  leading  to  ultimate 
atrophy. 

The  opiithalmoscopic  appearances  differ  according 
to  the  nature  of  the  injury.  If  the  central  artery  be 
divided  the  changes  are  like  those  met  with  in 
embolism  of  this  vessel.  In  other  cases  the  disc 
remains  normal  in  aspect  until  the  atrophic  process 
reaches  it,  when  it  gradually  assumes  the  appearance 
of  an  ordinary  secondary  atrophy  with  normal  vessels. 
The  treatment  of  the  recent  injury  must  be  based  on 
general  surgical  principles.  Later  on,  if  the  continuity 
of  the  nerve  has  been  preserved,  galvanism  may  be  of 
some  service. 

Tumours. — The  intra-ocular  end  of  the  nerve 
may  be  affected  secondarily  in  sarcoma  of  the  choroid 
or  in  retinal  glioma.  The  most  common  form  of 
tumour  proper  to  the  nerve  trunk  is  the  myxo- 
sarcoma. It  leads  to  proptosis,  papillitis  or  simple 
atrophy,  and  early  blindness ;  the  ocular  movements 
are  usually  good,  and  there  is  little  or  no  pain.  The 
intracranial  part  of  the  nerves  and  the  cbiasma  are 
especially  liable  to  gummata,  and  the  chiasma  may 
also  be  the  seat  of  a  deposit  of  cheesy  tubercle. 

Diseases  op  the  Retina. 

With  the  exception  of  its  blood-vessels  and  its 
pigment  epithelium,  the  retina  is  almost  perfectly 
transparent,    and    consequently   practically    invisible 


Retinal  Hemorrhages.  597 

ophthalmoscopically.  Its  diseased  conditions  may 
therefore  be  recognised  by  a  loss  of  its  transparency, 
or  by  changes  in  its  circulation  or  in  its  pigment 
layer.  Its  transparency  may  be  lost  over  a  small  or 
large  area  from  haemorrhages,  deposits  of  pigment, 
cedema,  exudations,  or  fatty  changes. 

HsBiiiori'hag'es  may  occur  at  any  part  of  the 
fundus,  and  may  be  single  or  multiple,  small  or  large. 
When  recent  they  present  a  bright  red  appearance, 
but  become  darker  with  time,  and  undergo  slow  ab- 
sorption. If  large,  they  may  either  burst  into  the 
vitreous  or  cause  detachment  of  the  retina.  When 
in  the  nerve  fibre  layer  they  present  a  striated  or 
"  flame-shaped  "  appearance,  and  when  in  the  deeper 
layers  they  are  round  or  irregular.  They  interfere 
with  vision  according  to  their  size  and  position,  those 
at  the  yellow  spot  causing  necessarily  much  impair- 
ment. 

Causes. — They  may  accompany  inflammation  of 
the  retina  or  optic  nerve,  but  are  more  frequently 
dependent  on  general  conditions,  or  on  retinal  disease 
consequent  on  general  conditions.  They  are  generally 
due  to  rupture  of  vessels,  as  from  increased  intra- 
vascular pressure  (e.g.  in  cases  of  contusion  of  the 
eye-ball,  optic  neuritis  with  much  constriction  of  veins, 
violent  effort,  or  high  arterial  tension),  or  from 
sudden  diminution  of  the  vitreous  support  (following 
wound  of  the  globe),  or  from  weakness  of  a  degener- 
ated vascular  wall.  Diapedesis  may  possibly  occasion 
visible  haemorrhages  in  cases  where  there  is  an  altered 
condition  of  the  blood,  e.g.  in  diabetes,  severe  antemia, 
leucocythsemia,  purpura,  pysemia,  etc.  They  are  also 
commonly  found  in  association  with  the  hsemorrhagic 
diathesis. 

The  treatment  must  be  mainly  determined  by 
the  patient's  general  condition,  but  local  application 
of  ice  may  be  employed  in  recent  cases. 


598  Manual  of  Surgery. 

Retinitis 
is  usually  tlie  result  of  some  general  disease,  and  the 
classification  of  its  forms  usually  adopted  is  a  clinical 
one. 

Syniptonis. — The  loss  of  vision,  both  temporary 
and  permanent,  varies  much  in  different  cases.  Oph- 
tlialmoscopically  we  find  loss  of  retinal  transparency, 
venous  dilatation,  and  a  tendency  to  the  occurrence 
of  haemorrhages  and  white  patches. 

The  treatment  depends  mainly  upon  the  patient's 
general  condition.  Complete  rest  must  be  ordered, 
and  all  strong  light  cut  off  by  wearing  dark  neutral 
tint  glasses.  Counter-irritants  and  leeches  to  the 
temple  are  sometimes  advisable. 

Tarieties. — 1.  HcBmorrhagic  retinitis  occurs  in 
association  with  disease  or  disorders  of  the  circulatory 
system,  and  usually  affects  one  eye  only.  The  haemor- 
rhages are  small  and  numerous. 

2.  Albuminuric  retinitis  is  most  commonly  asso- 
ciated with  chronic  kidney  disease,  especially  the  con- 
tracting form,  but  is  also  frequently  found  in  the 
albuminuria  of  pregnancy.  There  are  numerous  light- 
coloured,  soft-edged  patches  in  the  retina  ;  minute, 
opaque,  very  white  dots  or  striae  at  the  yellow  spot, 
arranged  in  the  form  of  an  asterisk,  with  its  centre  at 
the  fovea ;  and  generally  papillitis  and  haemorrhages. 
These  changes  may  subside  if  the  renal  affection  im- 
proves, those  at  the  macula,  however,  lasting  for  a 
long  time.  In  the  cases  associated  with  ])regnancy  we 
may  get  perfect  vision  restored  with  a  normal  fundus. 
3.  Syphilitic  retinitis  usually  comes  late  in  the 
secondary  stage,  about  the  end  of  the  first  year  or 
later.  The  ophthalmoscopic  changes  are  generally 
slight  :  the  larirer  veins  distended  and  dark,  and  the 
disc  outline  blurred.  Very  commonly  there  are  nu- 
merous dust-like  opacities  in  the  vitreous.  The  visua  1 
failui-e  is  considerable,  and  the  attack  lasts  for  months, 


Retinitis,  599 

but  the  result  is  generally  favourable.  The  treatment 
must  be  energetically  anti-syphilitic,  mercury  being  the 
remedy  chiefly  to  be  relied  on.  In  leucocythaemia, 
and  more  rarely  in  diabetes,  retinitis  may  also  occur. 

Retinitis  pig-nientosa  is  a  term  used  for  a 
disease  where  a  certain  group  of  symptoms  and  definite 
course  are  usually  found  in  association  with  pigmen- 
tary changes  in  the  retina.  The  disease  is  symmetrical 
and  chronic,  usually  beginning  in  early  life  and  ter- 
minating in  blindness  soon  after  middle  age.  Niglit 
blindness  is  the  earliest  and  most  characteristic  symp- 
tom. There  is  soon  loss  of  visual  field,  the  central  area 
remaining  longest.  Ophth. :  We  find  a  yellowish- red, 
"  waxy  "  atrophy  of  the  disc,  nan-owed  retinal  vessels, 
and  much  pigment  in  the  retina,  black  masses,  shaped 
somewhat  like  bone-corpuscles,  lying  superficial  to  the 
retinal  vessels.  Galvanism  is  the  only  form  of  treat- 
'nient  of  any  avail ;  it  sometimes  causes  improvement 
both  in  field  and  in  central  acuity.* 

Thrombosis  may  occur  in  the  central  artery  or 
vein,  but  neither  form  merits  separate  description 
here.  We  may  get  embolism  in  the  central  artery 
or  in  one  of  its  branches.  It  is  rarely  bilateral,  and 
is  more  common  on  the  left  side ;  the  usual  cause  is 
cardiac  disease.  In  a  case  of  complete  plugging,  the 
leading  symptom  is  sudden  blindness  of  one  eye. 
Ophth. :  The  disc  is  pale,  with  slightly  blurred 
edges.  There  is  a  diflPuse  haze  of  retina,  best  marked 
in  the  region  of  the  macula ;  corresponding  to  the 
fovea  centralis  is  a  bright  red  spot.  The  arteries 
near  the  disc  are  often  reduced  to  mere  white  threads. 
The  OTi\ J  treatm €71 1  that  has  proved  sometimes  bene- 
ficial is  massage  of  the  eye-ball,  probably  best  perfonned 
by  alternate  prolonged,  modei'ately  firm,  pressure  over 
the  globe  and  sudden  removal  of  this  pressure. 

In  retinal   detaeliment  the  retina  proper  is 
•  For  its  manner  of  employment  see  page  595. 


6oo  Manual  of  Surgery. 

separated  from  its  pigment  epithelium,  and  a  serous 
fluid  usually  occupies  the  interval.  The  fluid  may 
be  effused  primarily  as  a  haemorrhage,  or  as  a  serous 
exudation  in  connection  with  inflammation  or  tumour 
of  the  choroid.  The  common  reason  of  detachment, 
however,  is  some  alteration  in  the  vitreous,  either  a 
mere  diminution  of  its  support  to  the  retina,  or  cou- 
traction  of  connective  tisssue  formations  within  it 
dragging  the  retina  away  from  its  normal  position. 
Retinal  detachment  often  occurs  in  cases  of  progres- 
sive myopia.  On  illuminating  the  eye,  with  the 
mirror  held  at  twelve  to  eighteen  inches'  distance  from 
it,  we  find  that  some  part  of  the  fundus  gives  a  blueish- 
grey  or  whitish  reflex  instead  of  the  normal  red  seen 
elsewhere.  This  discoloured  detached  portion  is 
usually  folded  and  tremulous,  and  on  its  surface  the 
retinal  vessels  run  as  distinct,  slender,  dark,  tortuous 
lines.  In  a  recent  shallow  detachment  we  find  no 
such  diflference  in  colour,  but  its  vessels  have  the 
characters  just  mentioned.  We  should  always  note 
the  extent,  mobility,  depth,  and  degree  of  folding  of 
the  detachment ;  we  are  thus  in  a  position  to  decide 
as  to  the  probable  nature  of  the  displacing  agent. 

Symptoms. — There  is  frequently  a  history  of 
sudden  impairment  of  vision.  Generally  the  detach- 
ment gradually  extends  until  there  is  finally  complete, 
or  almost  complete,  blindness. 

Treatment. — Rest  in  the  recumbent  position  in 
a  dimly  lighted  room,  with  a  pressure  bandage  over 
the  eye,  is  advisable  in  recent  cases.  Puncture  of  the 
sclerotic  at  the  site  of  the  displacement,  so  as  to  per- 
mit the  subretinal  fluid  to  escape,  is  recommended, 
and  this  certainly  sometimes  improves  vision  con- 
siderably for  a  time. 

Olionia  of  the  retina  is  essentially  a  disease 
of  early  life.  It  commences  ir.sidiously,  without 
inflammation,  grows  rapidly,  and  if  left  to  itself  soon 


Chor  o  id  it  is.  6o  I 

leads  to  the  death  of  the  child,  spreading  both  cen- 
trally and  peripherally. 

Diagnosis. — The  attention  of  the  parents  is  gener- 
ally first  aroused  by  seeing  a  whitish  reflex  from  behind 
the  pupil.  By  this  time  there  are  often  signs  of  second- 
ary glaucoma,  and  the  eye  is  sometimes  tender.  By 
focal  illumination  we  see  a  yellowish-white,  rounded 
or  lobulated,  solid-lookmg  mass  in  the  vitreous,  with 
blood-vessels  and  often  small  hsemorrhas^es  on  its 
surface.  The  vessels  are  distinguished  from  those 
found  on  a  detached  retina  by  their  irregular  dis- 
tribution, different  mode  of  branching,  greater  breadth, 
and  somewhat  brighter  colour. 

The  treatment  is  early  removal  of  the  affected 
globe,  with  as  much  nerve  as  we  can  conveniently 
get.  If  the  other  orbital  contents  are  affected,  wdiile 
the  nerve  at  the  point  of  section  appears  healthy,  it 
is  advisable  to  thoroughly  clean  out  the  orbit  and 
then  destroy  the  surface  with  chloride  of  zinc  paste. 
When  the  tumour  has  attained  a  large  size  it  is  often 
prudent  to  leave  it  alone,  simply  giving  opiates,  if 
necessary,  to  relieve  pain  and  induce  sleep. 

Coug^enital  abiioriiiality. —  Opaque  nerve 
fibres  usually  occur  as  a  brilliantly  white  patch, 
narrower  at  the  end  next  the  papilla,  with  which  it 
is  nearly  always  continuous.  Its  broader  peripheral 
end  has  a  teased  out,  bi-ush-like  appearance  from  sepa- 
ration of  the  fibres.  The  affected  fibres  are  generally 
above  or  below  the  disc,  concecUing  the  large  blood- 
vessels more  or  less.  We  get  a  blind  spot  correspond- 
ing to  the  extent  of  the  opaque  area. 

Diseases  of  the  Choroid. 

Choroiditis. — From  the  absence  of  subjective 
symptoms  of  inflammation,  its  occurrence  is  usually 
diagnosed  from  vitreous  changes,  or  from  subsequent 
choroidal  atrophy  seen  ophthalmoscopically  as  white, 


6o2  -   Manual  of  Surgery. 

yellow,  or  black  spots  or  patches.  These  latter  vary 
in  size  from  mere  fine  points  to  areas  much  larger  than 
the  disc,  and  their  form  is  round  or  irregular.  They 
may  occur  only  at  the  macula,  at  the  equator,  or  over 
the  entire  fundus.  One  of  the  best  marked  clinical 
varieties  is  choroiditis  disseminata^  in  which  the 
atrophic  spots  are  generally  round,  white,  and  bor- 
dered by  a  ring  of  black  pigment ;  they  occur 
scattered  over  the  fundus,  but  principally  towards  the 
perii)hery.  This  variety  is  usually  symmetrical,  and 
in  association  with  syphilis. 

Causes. — Syphilis,  myopia,  senile  degeneration. 
When  seen  in  an  early  stage  or  while  the  sight  is  still 
failing,  the  treatment  should  consist  in  rest,  and 
anti syphilitic  remedies  when  indicated. 

Purulent  choroiditis  leads  to  secondary  infil- 
tration of  the  vitreous,  recognised  by  a  yellow  reflex. 
It  is  often  an  early  stage  of  panophthalmitis,  and 
always  leads  to  wasting  of  the  globe. 

Causes. — Injury,  septic  emboli  (as  in  puerperal 
fever  a^nd  pyaemia).  A  less  acute  form  is  met  with  in 
epidemic  cerebro-spinal  meningitis,  tuberculosis,  etc., 
leading  to  a  whitish  reflex  from  the  vitreous  and  partial 
jDhthisis  bulbi  (pseudo-glioma). 

Treatment. — In  traumatic  panophthalmitis,  early 
excision. 

Posterior  staphyloma.— A  certain  amount  of 
it  is  often  merely  a  stationary  congenital  peculiarity, 
usually  found  with  myopia,  and  exceptionally  with 
emmetropia  and  hypermetropia.  It  generally  occurs 
as  a  whitish  crescent  at  the  outer  edge  of  the  disc, 
with  sharp,  even  boundaries  and  a  dark  border. 
Another  form  is  progressive,  and  associated  with  high 
degrees  of  myopia ;  here  the  boundaries  are  less 
marked  and  frequently  indented,  the  pigment  border 
is  interrupted,  and  there  are  often  other  distmct 
patches  of  choroidal  disease  in  its  vicinity. 


Rupture  of  Choroid,  603 

Tubercle  of  the  choroid  is  generally  found  in 
the  neighbourhood  of  the  macula  and  papilla,  and 
usually  in  both  eyes.  Ophth. :  Yellowish  -  white, 
round,  somewhat  raised  spots,  varying  much  in  size. 

Cause. — Usually  miliary  tuberculosis  in  young 
subjects. 

Rupture  of  the  choroid,  from  a  direct  blow 
on  the  eye-ball,  generally  occurs  near  the  posterior  pole 
of  the  globe  in  the  form  of  a  crescent,  with  its  con- 
cavity towards  the  disc.  Opldli.  :  The  lissure  is 
white  or  yellowish  white ;  when  fresh,  haemorrhages 
are  often  found  at  or  near  it,  but  later  we  get  a  black 
pigmented  border. 

Colobonia  is  a  congenital  defect  at  the  lower 
part  of  the  choroid,  the  result  of  imperfect  closure  of 
the  foetal  cleft.  It  is  generally  of  large  size,  often 
extending  from  the  disc  to  the  periphery.  Ophth.  : 
We  find  an  uneven  surface  of  exposed  sclerotic  Avitli 
tortuous  vessels  on  its  surface,  and  often  surrounded 
by  black  pigment.  Coloboma  of  the  iris  frequently 
accompanies  it. 

Tuiuours.— J/e/ano^ic  sarcoma  is  much  the  most 
common  form ;  it  generally  occurs  at  or  past  middle 
life,  and  especially  in  eyes  damaged  by  injury  or 
disease.  Usually  the  patient  is  first  seen  in  a  com- 
paratively late  stage,  with  the  retina  largely  detached, 
the  eye  glaucomatous,  and  the  lens  often  cataractous. 
A  positive  diagnosis  is  then  difficult,  and  we  must  rely 
chiefly  upon  the  history.  Whenever  we  have  reason 
to  suspect  its  presence,  we  should  excise  at  once.  If 
the  nerve  at  the  point  of  section  be  afiected,  and  still 
more  if  the  tumour  have  perforated  the  outer  coats  of 
the  eye-ball,  all  the  contents  of  the  orbit  must  be 
removed,  and  chloride  of  zinc  paste  applied. 


6o4  Manual  of  Surgery. 

Diseases  op  the  Vitreous. 

Opacities  in  the  vitreous  are  generally  due  to 
inflammatory  afiections  of  this  structure,  occurring 
secondarily  to  disease  of  the  ciliary  body,  choroid, 
retina,  or  optic  nerve.  They  are  common  in  cases  of 
high  myopia.  They  may  also  be  the  result  of  haemor- 
rhages (from  rupture  of  retinal  or  choroidal  vessels),  or 
of  degeneration,  especially  senile.  Occasionally  we 
get  cholesterin  crystals  in  a  fluid  vitreous,  appearing 
as  a  sparkling  golden  shower  on  movements  of  the  eye 
{syiichysis  scintillans).  All  vitreous  opacities  are  best 
examined  with  a  plane  or  slightly  concave  mirror  held 
at  twelve  to  eighteen  inches  from  the  patient's  eye. 
On  his  turning  his  eye  smartly  upwards^  downwards, 
or  laterally  we  detect  the  opacities  against  the  red 
background  as  dark  webs  or  dots  which  are  still  in 
motion  after  the  eye  has  come  to  rest.  By  their 
rapidity  and  extent  of  movement  we  can  judge  of  the 
consistence  of  the  vitreous.  Sometimes  the  opacities 
are  very  minute,  like  small  dust  particles  difi'used 
throughout  the  vitreous,  e.g.  in  specific  choroiditis  ; 
these  are  well  seen  by  using  a  strong  convex  lens 
(  4-  18D)  behind  our  mirror  held  close  to  the  patient's 
eye  so  as  to  focus  them  accurately. 

Symptoms.  — He  generally  complains  of  seeing 
bbck  specks  floating  about,  and  sometimes,  especially 
where  the  opacities  are  large  and  central  or  diff*use, 
vision  is  much  reduced. 

Treatment. — Heurteloup's  leech  to  the  temple, 
along  with  the  remedies  appropriate  to  the  exciting 
cause.  The  dust-like  opacities  associated  with  specific 
disease  usually  disappear  under  a  mild  mercurial 
course. 

Suppurative  hyalitis  occurs  from  injury  or 
from  a  purulent  choroiditis.  We  get  a  yellowish  reflex 
from  the  j)urulent  deposit,  the  tension  is  reduced,  and 


Gla  ucoma.  605 

there  is  generally  iritis.  The  prognosis  is  unfavour- 
able, the  eye  being  usually  lost. 

Foreign  bodies  in  the  vitreous.— If  the  eye 

have  sufiered  irreparable  damage,  and  vision  be  much 
aflfected,  early  excision  is  best.  Where  the  lens  and 
ciliary  region  have  escaped,  and  there  is  no  evidence 
of  iritis  or  choroiditis,  we  may  try  to  remove  the 
foreign  body.  If  it  be  of  steel  or  iron,  the  electro- 
magnet is  exceedingly  useful  for  this  purpose.  If  it 
be  of  other  metal,  or  of  glass,  etc.,  it  will  be  found 
extremely  difficult  to  effect  its  removal,  unless  placed 
well  forward  in  the  equatorial  region.  If  evident 
inflammation  of  any  part  of  the  uveal  tract  occur  the 
eye  should  be  excised. 

Cysticercus  is  sometimes  found  in  the  vitreous, 
but  it  is  very  rare  in  this  country.  Persistent 
hyaloid  artery  occasionally  is  met  with,  appearing 
as  an  opaque  cord  running  forward  from  a  branch  of 
the  central  artery  on  the  disc. 

Glaucoma. 

"We  have  already  mentioned  the  occurrence  of 
secondary  glaucoma  in  several  ocular  affections  ;  we 
have  now  to  consider  the  primary  form  of  the  disease. 

Symptoms  and  mechanism.— Primary  glau- 
coma consists  mainly  in  an  increased  tension  of  the 
eye-ball  due  to  excess  of  fluid  within  the  vitreous 
chamber,  and  is  most  apt  to  occur  when  the  sclerotic 
is  unyielding  and  thick,  as  in  old  hypermetropic  eyes.* 

*  In  examining  tension  the  patient  stands  facing  us  with  head 
erect,  and  looks  down  towards  his  feet.  We  now  place  one  finger 
of  each  hand  on  the  upper  lid  of  the  eye  to  be  examined,  as  near  the 
upper  orbital  margin  as  possible,  and  press  the  globe  lightly  down- 
wards. Each  finger  is  used  alternately  simply  to  steady  the 
globe,  and  to  estimate  the  resistance  offered  to  light  pressure  when 
steadied  by  the  other  finger.  The  tension  of  the  two  eyes  should 
always  be  compared.  The  student  should  thoroughly  acquaint 
himself  with  the  average  tension  of  the  normal  eye,  so  that  he  may 
have  a  mental  standard  with  which  to  compare  alterations  in 
disease. 


6o6  Manual  of  Surgery. 

This  excess  of  fluid  is  partly  due  to  increased 
secretion  and  intra-ocular  vascular  congestion,  partly 
to  diminished  escape.  Continued  high  tension  in  the 
vitreous  chamber  will  mechanically  aflfect  every  part 
of  its  enclosing  walls.  The  soft  ciliary  body  soon 
yields  to  it,  and  we  get  rapid  failure  of  accommoda- 
tion (shown  by  increase  of  presbyopia),  often  a  valu- 
able early  symptom  of  the  disease.  The  ciliary  nerves 
are  also  affected  by  the  pressure,  and  this  result  as- 
s'sfcs  in  diminishing  the  accommodation,  besides  lead- 
ing to  dilatation  and  inactivity  of  the  pupil,  and  to 
corneal  anaesthesia.  A  sudden  access  of  tension  inter- 
feres with  the  circulation  in  the  choroidal  vessels,  and 
we  consequently  get  congestion  of  the  perforating  and 
other  branches  of  the  anterior  ciliary  veins  outside  the 
globe.  The  lens  is  pushed  forward  by  the  pressure 
behind,  and  the  anterior  chamber  rendered  shallow  in 
consequence.  The  peripheral  part  of  the  iris  is  also 
pressed  forward,  and  often  becomes  adherent  to  the 
inner  surface  of  the  cornea.  The  optic  nerve  and 
lamina  cribrosa,  being  of  less  resisting  power  than  the 
sclerotic,  ultimately  yield,  leading  to  cupping  and 
atrophy  of  the  disc.  The  intra-ocular  tension  being  as 
great  as,  or  even  greater  than,  that  in  the  central 
retinal  artery  except  during  systole,  we  get  arterial 
pulsation  evoked  by  gentle  finger  pressure  on  the 
globe,  or  occurring  spontaneously.  From  the  impeded 
blood  supply,  and  the  pressure  on  nerve  fibres,  there  is 
loss  of  function,  the  nasal  field  being  first  affected. 
Other  symptoms  of  glaucoma  are  steaminess  of  the 
cornea  and  pain,  and  the  patient  often  sees  coloured 
halos  round  a  flame.  The  pain  varies  greatly  in 
different  cases,  being  sometimes  absent,  and  sometimes 
very  severe,  referred  to  the  eye,  occiput,  and  back  par- 
ticularly, and  often  then  associated  with  sickness 
and  vomiting. 

Course. — Glaucoma    is   distinctly    a   progressive 


Gla  ucoma.  607 

disease,  leading  to  blindness,  but  the  rate  of  its  progress 
and  the  severity  of  its  symptoms  are  liable  to  much 
variation  in  different  cases,  and  often  in  the  same  case 
at  diflferent  times.  In  consequence  of  this  variability, 
different  forms  of  the  affection  are  described  as  acute, 
subacute,  and  chronic.  In  the  acute  form  the  symp- 
toms appear  suddenly,  and  are  very  severe,  the  con- 
gestion and  pain  being  especially  marked,  and  the 
tension  very  high.  Vision  fails  rapidly,  and  is 
generally  abolished  in  a  week  or  so  if  the  acute  symp- 
toms continue,  and  sometimes  even  in  a  few  hours 
{G.  fuhninans).  lu  chronic,  or  simple  glaucoma  there 
is  no  congestion  and  seldom  pain  ;  the  tension  is  never 
very  high,  and  all  the  other  symptoms  are  propor- 
tionately modified  and  the  progress  gradual,  lasting  for 
months  or  years  before  causing  total  blindness.  The 
subacute  form  is  intermediate  in  severity,  and  is  the 
most  common  in  occurrence,  frequently,  indeed,  ap- 
pearing intermittently  in  an  otherwise  chronic  case. 
There  are  considerable  congestion  and  pain,  and  the 
vision  fails  rapidly  ;  such  an  attack,  if  continuous, 
leads  to  complete  blindness  in  a  few  weeks.  Glaucoma 
usually  attacks  both  eyes,  though  not  necessarily  in 
the  same  form,  and  often  with  a  long  interval.  The 
second  eye  is  especially  liable  to  an  attack  immediately 
after  an  operation  {e.g.  iridectomy  or  excision)  on  the 
one  first  affected. 

Oeiieral  cauiscs. — It  seldom  occurs  before  forty- 
five  years  of  age,  and  is  most  common  in  women  and 
in  hypermetropic  eyes.  Grief,  anxiety,  overwork,  or 
the  local  use  of  atropine,  are  apt  to  bring  on  an  acute 
attack  in  those  otherwise  predisposed.  Its  subjects 
are  often  gouty.  The  different  theories  as  to  the  patho- 
logical origin  of  glaucoma  cannot  be  discassed  here.  The 
fundamental  aim  of  all  such  theories  is  either  to  explain 
a  hypersecretion  of  the  intra-ocular  fluids,  or  to  account 
for  their  abnormal  retention  within  the  globe. 


6o8  Manual  of  Surgery. 

T'reatment.— Iridectomy  gives  much  the  most 
satisfactory  results,  and  often  affords  permanent  relie£ 
The  incision  should  be  made  well  behind  the  apparent 
corneal  margin,  and  the  excised  piece  of  iris  removed 
well  up  to  its  ciliary  attachment.  This  operation  is 
particularly  indicated  in  all  acute  and  subacute  cases, 
and  should  be  performed  at  the  earliest  possible  op- 
portunity. When  a  painful  glaucomatous  eye  is  per- 
manently blind,  iridectomy  may  be  done  for  relief  of 
pain,  but  enucleation  is  usually  preferable  in  such 
cases.  In  true  chronic  glaucoma  treatment  is  often 
of  no  avail,  but  even  here  iridectomy  is  always  worth 
trying,  as  it  is  more  likely  than  anything  else  to  give 
relief.  Some  surgeons  prefer  sclerotomy  in  this  form 
of  the  disease,  the  operation  consisting  practically  in  a 
large  incision  through  the  anterior  part  of  the  scle- 
rotic, without  iridectomy.  Userine  is  often  service- 
able by  keeping  the  tension  temporarily  diminished  in 
the  more  acute  cases,  when  for  some  reason  iridectomy 
must  be  deferred.  It  may  also  be  used  in  chronic 
forms  as  a  preliminary  to,  or  instead  of,  operation.* 
Eserine  should  always  be  employed  as  a  prophylactic 
agent  for  the  one  eye  when  the  other  requires  opera- 
tion for  increased  tension  ;  in  such  a  case  it  is  suffi- 
cient to  use  it  just  before,  and  for  two  or  three  days 
subsequent  to  the  operation.  In  all  cases  of  glaucoma 
rest  must  be  insisted  upon,  errors  in  diet  avoided,  and 
causes  of  mental  excitement,  as  far  as  possible,  re- 
moved. Atropine  and  similar  mydriatics  must  never 
be  used  where  a  predisposition  to  glaucoma  exists^  still 
less  when  the  disease  is  actually  present. 

•  In  glaucoma  I  have  found  a  solution  containing  eserine  and 
cocaine  serviceable,  the  latter  (by  its  stimulant  action  on  the  sym- 
pathetic nerves)  presumably  preventing  the  internal  vascular  con- 
gestion usually  caused  by  eserine.  Such  dilatation  of  pupil  as 
cocaine  would  naturally  cause,  is  readily  overcome  by  very  weak 
eserine.  R  Cocain.  hydrochlor.  gr.  v  ;  eser.  sulphat.  gr.  j  ;  aq. 
destUl.  3j.     One  drop  four  to  six  times  daily. 


Errors  of  Refractiox.  609 

Errors  of  Refraction  and  Accommodation. 

The  eye  sees  by  virtue  of  the  rays  of  light  which 
have  passed  through  its  pupil  and  reached  its  retina. 
For  the  formation  of  defined  images,  it  is  necessary 
that  the  rays  coming  from  an  object  be  accurately 
focussed  on  the  outer  segments  of  the  rod  and  cone 
layer  ;  the  normal  or  eynmetropic  eye,  with  relaxed 
accommodation,  is  such  that  parallel  rays  are  so  fo- 
cussed. In  myopia  the  retina  is  placed  too  far  back, 
so  that  ]:iarallel  rays  come  to  a  focus  in  front  of  it,  and 
the  resulting  retinal  image  is  consequently  ill-defined. 
In  hijpei'metropia,  on  the  contrary,  the  antero-posterior 
measurement  of  the  eye  is  too  short,  so  that  the  rays 
have  not  yet  come  to  their  focus  when  they  reach  the 
sentient  retina,  and  a  blurred  image  is  again  the  re- 
sult. 

The  rays  coming  from  every  point  of  an  object  are  divergent, 
but  when  such  object  is  situated  at  several  feet  distance  from  the 
eye,  those  passing  through  the  pupil  may,  for  all  practical  pvir- 
Ijoses,  be  considered  parallel.  It  is  usual  to  place  our  test  object 
at  six  metres  (or  twenty  feet)  in  testing  the  refraction  of  the  eye 
at  rest.  To  be  accurately  seen  by  the  average  eye,  an  object  must 
be  of  such  a  size  that  it  subtends  an  angle  of  five  minutes,  the  apex 
of  the  angle  being  situated  near  the  i)osterior  pole  of  the  lens, 
where  the  rays  coming  from  all  eccentric  points  of  the  object 
cross  the  principal  axis.  The  test  types  usually  employed  (Snel- 
len's) are  made  on  this  principle,  and  we  express  the  visual  acuity 
(V)  by  a  fraction,  the  numerator  corresponding  to  the  distance  (in 
metres  or  feet)  between  the  patient's  eye  and  the  test,  the  denomi- 
nator being  the  distance  at  which  the  type  ought  to  be  distin- 
guished by  the  normal  eye.  Thus,  with  normal  vision,  V  =  §  (or 
|§),  but  if  the  smallest  type  read  at  six  metres  is  that  which  ought 
to  be  distinguished  at  twelve  or  at  sixty  metres,  V  =  ^%  or  ^ ; 
i.e.  =  ^  or  ^th  of  normal  vision.  Each  eye  must  always  be  tested 
separately. 

We  cannot  here  consider  the  subject  of  optics  further  than  to 
remind  the  student  that  an  ordinary  convex  or  +  lens  renders 
divergent  rays  less  divergent,  parallel,  or  convergent,  according  to 
the  amount  of  the  divergence  of  the  original  rays  and  the  strength 
of  the  lens.  Kays  already  parallel  it  brings  to  a  focus  at  a  dis- 
tance varying  inversely  with  the  curvature  of  the  lens.  By  in- 
creasing the  curvature  of  a  lens,  therefore,  we  augment  its  etfect 

NN— 21 


6io  Manual  of  Surgery. 

on  divergent  rajs,  ami  render  its  focussing  distance  for  parallel 
rays  shorter.  An  ordinary  concave  or  —  lens  increases  the  diver- 
gence of  already  divergent  rays,  and  makes  pai'allel  rays  diverge  as 
if  coming  from  a  point  in  front  of  the  lens  ;  the  inteival  between 
this  point  (or  virtiuil  focus)  and  the  lens  is  the  focal  distance  of 
the  lens  in  question.  A  lens,  whose  focal  distance  is  one  metre,  is 
called  one  dioptre  (1  d),  and  is  the  unit  of  the  metric  system  now 
■generally  adopted  ;  a  lens  of  two  dioptres  (2  d)  is,  therefore,  twice 
the  strength,  or  one-half  the  focal  distance. 

Enimetropia  (^E)  and  presbyopia  [Pr). — Were 
it  not  for  the  power  of  accommodation,  the  normal 
eye  would  be  incapable  of  seeing  near  objects  dis- 
tinctly, as  the  rays  would  be  too  divergent.  By  the 
action  of  the  ciliary  muscle,  however,  the  curvature  of 
the  crystalline  lens  can  be  increased,  so  that  rays  of 
very  considerable  divergence  can  be  brought  to  a 
focus  on  the  retina.  This  temporary  increase  in  cur- 
vature (or  accommodation)  is  dependent  on  the  elas- 
ticity of  the  lens  substance,  and  diminishes  with  age. 
Whenever  it  has  failed  so  much  that  objects  must  be 
placed  at  nine  inches  or  more  from  the  eye  so  as  to  be 
clearly  seen,  the  condition  of  presbyopia  is  said  to 
exist,  and  the  increased  curvature  required  must  be 
artificially  supplied  by  suitable  convex  glasses.  Pres- 
byopic glasses  of  Id  are  necessary  in  the  emmetropic 
eye  at  about  45  years  of  age,  and  they  require  to 
be  increased  by  about  Id  for  each  five  years  of  life 
up  to  the  age  of  60,  and  afterwards  by  0'5d  for  each 
subsequent  five  years. 

Hypermetropia. — Although  all  objects  must  ap- 
pear indistinct  to  thehypermetrope  with  relaxed  accom- 
modation, he  is  able  to  see  distinctly  by  an  effort  of 
his  ciliary  muscle  provided  he  be  still  young  and  the 
hypermetropia  not  very  large  in  amount.  Some  such 
effort  is  necessary  even  for  distant  objects,  but  a 
greater  is  required  for  all  near  vision.  In  as  far  as 
convergence  and  accommodation  are  naturally  consen- 
taneous acts,  such  a  hypermetrope  is  apt  to  develop  a 
convergent  concomitant  squint,  and  a  continuance  of 


Myopia.  6  i  i 

the  accommodative  effort  leads  to  fatigue,  supra- 
orbital headache,  and  occasional  blurriiiir  of  imairoy 
from  failure  to  maintain  the  accommodation  neces- 
sary. The  glass  suitable  for  such  an  eye  is  a 
convex  one,  of  such  a  strength  that  jjarallel  rays 
will,  by  its  aid,  be  focussed  on  the  retina  without  the 
use  of  accommodation.  To  overcome  all  action  of  the 
ciliary  muscle  in  young  people  it  is  necessary  to  use 
atropine,  but  the  full  correction  found  under  its  use 
should  not  be  ordered,  a  glass  of  1  D  less  than  this 
being  most  suitable.  The  hypermetrope  should  wear 
his  glasses  constantly. 

Myopia.— For  distinct  vision  the  object  must  be 
comparatively  near  the  eye,  so  that  the  rays  coming 
from  it  and  passing  through  the  pu[)il  have  such  a 
divergence  that  they  will  be  focussed  on  the  retina. 
Distant  objects  can  only  be  rendered  distinct  by  the 
aid  of  a  concave  lens,  and  the  weakest  that  will  give 
this  result  must  be  the  one  ordered.  Should  there 
be  insufficiency  of  the  internal  recti,  prisms  with  their 
bases  inwards  are  often  very  serviceable  for  near  work. 

Astig^iiiati^ni.  —  In  regular  astigmatism  one 
meridian  of  the  eye  is  of  less  refractive  power  than 
any  other,  and  at  right  angles  to  this  is  the  meridian 
of  greatest  refraction.  If  one  meridian  be  emmetropic 
while  the  opposite  is  myopic  or  hypermetropic,  we  have 
respectively  simple  myopic  or  simple  hypermetropic 
astigmatism.  If  both  such  meridians  be  unequally 
myopic  the  condition  is  called  compound  myopic 
astigmatism  ;  if  both  be  unequally  hypermetropic  we 
have  compound  hypermetropic  astigmatism.  Again, 
if  one  meridian  be  hypermetropic,  while  that  at  right 
angles  to  it  is  myopic,  the  case  is  one  of  mixed  astig- 
matism. The  consequence  of  astigmatism  is  that  no 
object  is  seen  with  perfect  distinctness,  but  any 
straight  line  will  be  comparatively  well  defined  if  at  a 
Buitable   didance  from  the  eye.     The  correcting  glass 


6i2  Manual  of  Surgery. 

required  is  a  cylindrical  one  (-f  or  — ),  witli  a 
spherical  in  addition  where  the  astigmatism  is  com- 
pound or  mixed. 

Affections  of  Ocular  Muscles. 

Convergent  strabismus  of  a  concomitant 
nature  has  already  been  mentioned  when  considering 
hypermetropia.  It  usually  first  appears  in  early  child- 
hood, and  may  only  be  periodic,  or  worse  during  strong 
accommodative  efforts,  but  sometimes  it  is  constant  in 
presence  and  in  degree.  If  both  eyes  see  equally  well, 
it  is  often  alternating,  affecting  sometimes  one,  some- 
times the  other  eye.  In  the  constant  form,  diplopia 
is  generally  avoided  by  a  mental  suppression  of  the 
image  from  the  squinting  eye,  which  latter  conse- 
quently becomes  defective.  Occasionally  the  squint 
disappears  spontaneously  after  some  years. 

Treatment. — The  glasses  required  for  the  hyper- 
metropia are  usually  sufficient  to  prevent  a  concomi- 
tant squint  if  given  sufficiently  early.  When  the 
squint  persists,  however,  after  using  glasses  for  some 
time,  one  internal  rectus  should  be  divided,  and  if 
this  be  insufficient  the  other  eye  may  also  be  operated 
on  some  weeks  later. 

Divergent  strabismus  not  infrequently  occurs 
in  myopia  from  insufficiency  of  the  internal  recti ; 
here,  again,  diplopia  seldom  exists  when  the  squint  is 
constant.  The  treatment  consists  in  giving  the  requi- 
site glasses  and  dividing  one  or  both  external  recti. 
Divergent  strabismus  also  often  afJects  an  eye  whose 
vision  is  defective,  as  from  corneal  opacities. 

Ocular  paralysis.  —  Paralysis  of  the  nerves 
supplying  the  extra-ocular  muscles  leads  to  strabismus, 
and  to  di[»l.opia,  whicli  latter  is  always  more  trouble- 
some when  the  strabismus  is  slight,  i.e.  when  the 
double  images  appear  close  together.  The  false  image 
is  always   displaced    in    the    direction   in   which  the 


Stka  bjsmus.  6 1 3 

affected  muscle  would  act  were  it  not  paralysed.  The 
strabismus  is  due  to  the  unopposed  action  of  the  sound 
muscles.  Such  a  paralysis  is  usually  uni-ocular.  The 
whole  of  the  third  nerve  is  seldom  equally  affected, 
one  or  more  branches  generally  suffering  more  than 
the  others.  Very  rarely  we  get  all  the  extra-ocular 
muscles  paralysed  {ophtludmoplegia  externa)  in  both 
eyes. 

Paralysis  of  the  intra-ocular  muscles. — The  iris 
(sphincter  and  dilator)  and  the  ciliary  muscle  may  be 
affected  separately  or  together.  In  third  nerve  par- 
alysis the  sphinctor  iridis  and  ciliary  muscle  are  usually 
both  affected.  Paralysis  of  all  three  intra-ocular 
muscles  (ojihthalmoplegia  interna)!^  occasionally  found. 

Causes. — Syphilis  is  a  frequent  source  of  these 
affections,  either  by  a  periostitis  (at  the  base  of  the 
skull  or  at  the  sphenoidal  fissure)  or  by  gummata 
somewhere  in  the  course  of  the  nerves  or  at  cerebral 
centres.  Other  causes  are  meningitis,  orbital  or  intra- 
cranial tumours  and  fracture  of  the  skull.  Some 
cases  are  said  to  be  rheumatic  in  origin.  Paralysis  of 
the  ciliary  muscles  (cycloplegia)  is  not  uncommon  after 
diphtheria.  In  an  early  stage  of  tabes  dorsalis,  tem- 
porary localised  extra-ocular  paralyses  are  sometimes 
observed,  and  in  a  later  stage  of  this  affection  we  get 
a  form  of  iridoplegia  in  which  the  pupils  do  not  re- 
act to  light,  but  still  contract  on  convergence  of  the  eyes. 

Treatment. — Where  syphilis  is  a  possible  cause 
•we  should  give  a  course  of  mercury  and  iodide  of 
potassium.  Galvanism  may  also  be  employed.  In 
stillation  of  a  weak  solution  of  eserine  {h  or  1  gr.  to 
the  ounce)  is  useful  in  post-diphtheritic  cycloplegia.  In 
some  incurable  cases  the  diplopia  may  be  prevented  by 
the  use  of  prismatic  glasses,  and  the  pupil  may  be 
restored  to  its  normal  size  and  the  ciliary  muscle 
stimulated  by  a  solution  of  eserine  of  an  appropriate 
strength,  accordinor  to  the  effect  desired. 

N  X*— 2] 


6i4  Manual  of  Surgery. 

Nystag^iiiu^,  or  involuntary  oscillation  of  tlie 
eye-ball,  may  be  vertical,  horizontal,  or  rotatory.  It  is 
generally  due  to  congenital  or  early  infantile  defect  of 
vision,  and  usually  affects  both  eyes.  It  is  also  occa- 
sionally found  in  coal  miners,  pro'l3ably  from  the  com- 
bined influence  of  insufficient  light  and  of  a  constantly 
strained  unnatural  position  of  the  eyes  when  at  work. 
This  latter  form  may  be  cured  by  change  of  employment, 
but  ordinary  nystagmus  does  not  yield  to  treatment. 

Diseases  of  the  Orbit. 

Periostitis  usully  affects  the  orbital  margin,  and 
is  most  common  in  sti'umous  children ;  sometimes  it 
IS  due  to  injury  or  syphilis. 

Symptoms.  —  Dull  pain,  circumscribed  swelling 
with  redness,  and  much  tenderness  to  finger  pressure. 
At  first  the  swelling  is  hard,  but  it  usually  softens 
later  on  the  foiTaation  of  pus,  and  on  puncture  bare 
bone  may  be  detected  by  the  probe.  If  the  disease 
be  deep  in  the  orbit,  the  general  symptoms  are  more 
severe,  and  the  eye-ball  is  pushed  forward  or  displaced 
laterally. 

Course. — As  a  rule  such  cases  do  well,  but  some- 
times deeply  seated  periostitis  or  caries  may  cause 
optic  atrophy,  or  even  endanger  life  by  the  inflamma- 
tion spreading  to  the  meninges  or  causing  venous 
thrombosis. 

Treatment. — Poulticing  or  hot  fomentations.  Earlv 
evacuation  of  pus.  Constitutional  treatment  as  indicated. 

Orbital  cellulitis. — Symjjtoms. — Proptosis  and 
impaired  movements  of  globe,  conjunctival  chemosis, 
redness  and  swelling  of  lids  ;  severe  localised  pain  and 
general  fever.  On  pus  forming,  we  find  a  circum- 
scril)ed,  fluctuating,  conjunctival  bulging.  Sometimes 
we  get  optic  neuritis,  or  even  purulent  choroiditis,  and 
still  more  rarely  we  may  have  pyaemia  or  purulent 
meningitis. 


Diseases  of  the  Orbit.  615 

Causes.  —  WouuJs,  spreading  of  inflammation 
from  a  neighbouring  cutaneous  erysipelas  or  from 
caries.  Sometimes  it  is  metastatic,  as  in  splenic  fever, 
glanders,  or  pyaemia. 

Treatment. — As  of  last  affection. 

Tumours  in  this  situation  usually  cause  prop- 
tosis  and  impairment  of  ocular  movements,  and  often 
lead  to  papillitis  or  optic  atrophy.  Both  orbits  are 
rarely  affected.  The  i^imary  tumours  are  cystic 
(dermoid,  cysticercus),  sarcomatous,  bony  (ivory  exos- 
tosis), and  vascular.  In  the  vascular  variety  we 
usually  get  a  bruit  heard  over  the  orbit  and  adjacent 
part  of  the  skull,  and  often  visible  pulsation.  The 
secondary  tumours  arise  in  the  globe  itself  or  in  the 
neighbouring  parts.  Many  of  the  vascular  tumours 
here  are  intracranial  in  origin,  the  most  common  being 
arterio-venous  aneurism  from  rupture  of  the  internal 
carotid  into  the  cavernous  sinus,  generally  caused  by 
fracture  of  the  base  of  the  skull. 

Treatment.  —  Cysts  may  be  evacuated  by  free 
incision  (after  needle  puncture  so  as  to  eliminate  the 
remote  possibility  of  its  being  an  encephalocele). 
Exostoses,  when  not  attached  to  the  thin  upper  wall, 
and  wlien  their  base  is  narrow,  may  be  removed. 
Malignant  tumours  slioukl  be  removed  early  along 
with  the  eye-ball  and  all  the  orbital  contents,  and 
chloride  of  zinc  paste  then  applied.  In  many  vascular 
tumours  ligature  of  the  common  carotid  is  advisable  ; 
digital  compression  may  be  tried  as  a  preliminary. 


INDEX  TO  VOLUME  II. 


Abscess,  Iliac,  43  >,  43*^ 

,  Lumbar,  436,  438 

of  bone,  101,  104,  107,  112 

,  Psoas,  436 

Acetabulum,   Fracture   through, 

61 
Acromion,  Fracture  of,  38 
Amputation  in  joint  disease,  269, 

295 
Aneurism  of  bone,  144 
Angina  Ludovici,  477 
Ankle,  Dislocation  of,  201 
joint,    Strumous  disease  of, 

302 
Ankylo-blepbaron,  543 
Arthritis,  235 

,  Acute,  of  infants,  238,  239 

Astigmatism,  611 
Astragalus,  Dislocation  of,  205 

,  Fracture  of,  92 

Atrophy  of  bone,  130,  136 
Auditory  meatus,  Atiections   of, 

527 

,  Foreign  bodies  in,  527 

Aural  catarrh,  531 

polypi,  536 

Auricle,  Diseases  of,  536 

Back,  Injuries  of,  447 

,  Sprains  of,  449 

Bfed-sores  in  spinal  injuries,  465 
Bladder  in  spinal  injuries,  462 
Blephantis,  540 
Blepharospasm,  544 
Bone,  Abscess  of,  101,  104,  107, 
112 

,  Atrophy  of,  130,  136 

,  Contusions  of,  27 

,  Cysts  of,  148 

,  Diseases  of,  93 

■ ,  Exfoliation  of,  124 

,  Fibrous  tumours  of,  148 

,  Hypertrophy  of,  128,  137 

,  Inflflmmation  of,  93 

,  Pulsative  tumours  of,  143 


Bone,  Sarcoma  of,  140,  141 

,  Sclerosis  of,  101,  104,  110 

,  Scrofula  of,  13  L 

,  Syphilis  of,  134.J136 

,  Tubercle  of,  131 

■ ■,  Tumours  of,  140 

,  Wounds  of,  26 

Bow  legs,  361 

Bowel  in  spinal  injuries,  463 
Brain,   Compression  of,  401,  409 
410,  412 

,  Concussion  of,  401,  402,  410 

,  Contusion  of,  4C7 

-,  Inflammation  of,  406,  4 16 

,  Irritation  of,  404 

,  Laceration  of,  401,  409 

,  Topography  of,  423 

Bronchocele,  491 
Bryant's  triangle,  65 
Bursae,  Diseases  of,  319,  321 
Bursitis,  319 

Callus,  18 
Caries,  101,  104 

f  ungo?a,  107 

necrotica,  107 

of  nose,  515 

of  skull,  372 

sicca,  106 

Carpus,  Fracture  of,  59 
Cataract,  683 

,  Causes  of,  585 

,  Treatment  o%  586 

,  Varieties  of,  583 

Cephalhsematomata,  367 
Cerebral  tumours,    Eemoval    of 

378 
Chalazion,  546 
Choroid,  Diseases  of,  601 
Choroiditis,  601 
Ciliary  region,  Diseases  of,  579 
Clavicle,  Dislocation  of,  167,  171 

,  Fracture  of,  32 

,  Separation  of  epiphysis  of, 

35 


Index. 


617 


Cline's  splint,  88 
Chib  foot,  338 

hand,  338 

Coccyx,  Fracture  of,  62 
Colles'  fracture,  53 
Coloboma,  545,  578,  603 
Compression  of  braiu,   401,    -109, 

41(1,  412 
Concussion  of  brain,  401,  402,  410 

of  spinal  cord,  470 

Conjunctiva,  Diseases  of,  549 
Conjunctivitis,  549 
Contusions  of  joints,  149 
Cornea,  Abscess  of,  569 

,  Conical,  571 

,  Diseases  of,  562 

,  Injuries  of,  572 

,  Ulcers  of,  565 

Coryza,  510 

Cranial  nerves,  Injuries  of,  418 

Cranio-tabes,  137 

Cranium,  Contusions  of,  391 

Croft's  splint,  10 

Croup,  503 

Cut-tkroat,  473 

Cyclitis,  579 

Cyphosis,  336,  445 

Cysts  of  bone,  148 

of  neck,  480 

Deaf  mutism,  538 
Deafness,  633,  539 
Dermoid  cysts  of  sculp,  3  58 
Digits,  Deformities  of,  363 
Diphtheria,  503 
Dislocations,  158 

,  Causes  of,  159 

,  Complications  of,  160 

,      Special.      (See    indixidi.al 

joints  and  bones.) 

,  Symptoms  of,  160 

,  Treatment  of,  161 

unreduced,  163 

Distichiasis,  542 
Dupuytren's  contraction,  318 

fracture,  b7,  202 

splint,  90 

Dura  mater.  Fungus  of,  375 

Ear,  Diseases  of,  524 

Ectropion,  544 

Elbow,  Dislocation  of,  180 

joint,  Disease  of,  273 

Emmetropia,  610 
Encephalitis,  416 
Encephalocele,  370 
Enchondroma,  147 
Ivndosteitis,  114 
Eutropiou,  &43 


Epicanthus,  545 
Epiphora,  547 
Epiphysitis,  117,  119,  238 
Epistaxis,  507 
Eustachian  catheter,  533 
Excision  of  joints,  263,  293 
Exostosis,  145 
Eye,  Diseases  of,  540 

Fasciae,  Conti-action  of,  318 

,  Injuries  of,  317 

Fat  embolism,  15 
Femur,  Dislocation  of,  186 

,  Fracture  of,  63 

,  Separation  of  epiphyses  of, 

69,  71,  77 
Fibrous  tumours  of  bone,  148 
Fibula,  Dislocation  of,  2ul 

,  Fracture  of,  86 

Flat  foot,  352 

Follicular  ulcer  of  scalp,  367 
Foot,  Dislocation  of,  201 
Fractures,  1 

,  Causes  of,  3 

,  Complications  of,  13 

,  Compound,  1,  11 

,  Delayed  union  of,  22 

,  General  treatment  of,  7 

,  Greenstick,  1 

,  Intra-uterine,  5 

,  Non-union  of,  23 

of  skull,  398 

,  Repair  of,  18 

,  Special.       (See      individual 

bones.) 

,  Symptoms  of,  5 

,  Union  of,  with  deformity, 

25 

,  Varieties  of,  1 

Fragilitas  ossium,  130 
Fungus  of  dura  mater,  375 

Ganglion,  315 
Genu  valgum,  356 

varum,  361 

Glaucoma,  605 

,  Causes  of,  607 

,  Course  of,  006 

,  Symptoms  of,  605 

,  Treatment  of,  608 

Goitre,  491 

Gronorrhoeal  synovitis,  229 

Gout,  219 

Hallux  valgus,  361 

varus,  361,  363 

Hammer  toes,  36.3 
Head,  Diseases  of,  365 
,  Injuries  of.  3S0 


6i8 


Manual  of  Surgery. 


Hereditary     syi)Lilis,    Boue    dis- 
eases of,  136 
Hernia  cerebri,  419 
Hip,  Disease  of,  277 

,  Dislocation  of,  186 

Hodgen's  splint,  76 

Hordeolum,  541 

Horns,  368 

Humerus,  Dislocation  of,  Vi'l 

,  Fracture  of,  41 

Hyalitis,  604 
Hydrencephalocele,  370 
Hydrocele  of  neck,  481 
Hydrocephalus.  376 
Hydrops  articuli,  232 
Hypermetropia,  610 
Hypertrophy  of  bone,  128,  137 

Internal  ear,  Diseases  of,  537 
Iris,  Diseases  of,  573 

,  Injuries  of,  577 

,  Tumours  of,  577 

Iritis,  573 

,  Eesults  of,  576 

,  Varieties  of,  575 

Jaw,  Dislocation  of,  165 

,  Fracture  of,  28 

Joints,  Contusions  of,  119 

,  Diseases  of,  210 

,  Dislocation  of,  158 

, ,  Causes  of,  159 

, ,  Comj)licatio*.is  of,  KJO 

, ,  Symptoms  of,  160 

,  Injuries  of,  149 

,  Sprains  of,  150 

,  Tumours  of,  260 

,  Woiinds  of,  152 

Keratitis,  562 

,  Interstitial,  570 

punctata,  569 

Knee,  Dislocations  of,  197 

joint,  Disease  of,  297 

Knock  knee,  356 
Kyphosis,  336,  445 

Laceration  of  brain,  401,  409 
Lacrymal  abscess,  548 

apparatus.  Affections  of,  547 

,  Bone,  fracture  of,  27 

gland,  Affections  of,  546 

Laryngitis,  502 

Larynx,  Affections  of,  495 

,  Excision  of,  502 

,  Foreign  bodies  in,  496 

,  Fractures  of,  495,  496 

,  Iiifliimmation  of,  502 

• ,  Scalds  of,  495 


Larynx,  Tumours  of,  500 

,  Wounds  of,  474 

Lateral  curvature  of  spine,  327 
Lens,  Diseases  of,  583 

,  Injuries  of,  588 

Leontiasis  ossea,  129 
Lids,  Affections  of,  540 
Lipoma  nasi,  521 
Listou's  splint,  74 
Loose  bodies  in  joints,  250 
Lordosis,  336 

Macintyre's  splint,  75 

Malacosteon,  138 

Malar  bone,  Fracture  of,  28 

Marrow,  Inflammation  of,  114 

Mastoid  process.  Diseases  of,  536 

Medullitis,  114 

Membrana  tymi^ani,  Affections  of, 

535 
Meniere's  disease,  537 
Meningitis,  416,  454 
Meningocele,  370 
Metacarpvis,  Fracture  of,  59 
Metatarsus,  Dislocation  of,  209 

,  Fracture  of,  92 

Mollities  ossium,  138 
Morbus  coxae,  279 
IMumps,  487 
Muscles,  Atrophy  of,  3<>6 

,  Hypertrophy  of,  306 

,  Inflammation  of.  305 

,  Ossification  of,  310 

,  Rupture  of,  304 

,  Tumours  of,  310 

,  Woimds  of,  301- 

IMyeloid  sarcoma,  141 
Myopia,  611 
Myxcedema,  491 

Nasal  bones,  Fracture  of,  27 

catarrh,  510 

cavities.  Tumours  of,  516 

duct,  Strict'ires  of,  548 

polypi,  516 

Neck,  Cellulitis  of,  477 

,  Contusions  of,  472 

,  Diseases  of,  472 

,  Iij juries  of,  472 

,  Tumours  of,  480,  485 

,  Wounds  of,  472 

Necrosis,  120 

,  Acute,  98,  115 

of  nasal  bones,  515 

of  skuU,  373 

,  Phosphorus,  ?28 

,  Quiet,  127 

N^laton's  line,  &5 

Nerves,  Cranial,  Injuries  of,  418 


Index. 


619 


Nodes,  P6,  133, 134,  137 
Nose,   Atiectious  of  septum    of, 
521 

,  Deformities  of,  520 

,  Diseases  of,  507 

— — ,  Foreign  bodies  iu,  500 

,  Wounds  of,  507 

Nystagmus,  614 

Ocular  muscles,  Affections  of,  612 

,  Pnralysis  of,  612 

Olecranon,  Fracture  of,  57 
Ophthalmia,  Diphtheritic,  556 

,  Gronorrhceal,  551 

^—,  Granular,  554 

• neonatorum,  553 

,  Purulent,  550 

,  Simple,  549 

Ophthalmoplegia.  613 
Optic  neuritis,  589 

• nerve.  Atrophy  of,  592 

,  Diseases  of,  589 

,  Injuries  of,  595 

• ,  TumouTB  of,  5.% 

Orbit,  Diseases  of.  614 

■ ,  Periostitis  01,  614 

,  Tumours  of,  615 

Orthopaedic  surgery,  324 
Os  calcis.  Fracture  of,  92 
Osteitis,  93,  100,  104 

deformans.  129 

of  skull,  391 

Osteo-aneurism,  143 

-malacia,  138 

myelitis,  114, 115 

porosis,  101,  104 

sclerosis,  101,  104,  110 

Osteoma,  145 
Osteophytes,  96,  137 
Osteoplastic  osteitis,  101,  104,  110 
Osteotomy,  359 
Othaeujatoma,  530 
Otorrhagia,  528 
Otorrhoea,  535 
Ozaena,  514 

Pachydermatocele,  368 
Palmar  fascia.  Contraction  of,  318 
Papillitis,  587 
Paronychia  tendinosa,  314 
Parotid  gland,  Inflammation  of, 
487 

. ,  Tumours  of,  488 

Parrot's  nodes,  137 
Patella,  Dislocation  of,  195 

,  Fracture  of,  78 

Pelvis,  Fracture  of,  60 
Pericranium,  Injuries  of,  390 
Periosteal  abscess,  95 


Periosteal  nodes,  96,  133,  134 
Periostitis,  94—98  • 

of  skull,  391 

Phalanges,  Fracture  of,  60,  92 
Phlyctenular  affections  of  eye,  560 
Phosphorus  necrosis,  128 
Pinguecula,  559 
Pneumatocele,  369 
Politzerisation,  532 
Pott's  disease  of  spine,  432,  445 

fracture,  86,  89,  202 

Presbyopia,  610 

Priapism,  464 

Pseudo  -  hypertrophic     paralysisj 

308 
Psoas  abscess,  436 
Pterygium,  559 
Ptosis,  545 
Pulpy  degeneration  of  joints,  249 

Quiet  necro.-is,  127 

Radius  and  ulna.  Fracture  of,  5 

,  Dislocation  of,  180,  183 

,  Fracture  of,  52 

Railway  spine,  452,  471 
Rarefying  osteitis,  101,  104 
Refraction,  Errors  of,  6<,>9 
Repair  of  fractiu-es,  18 
Retina,  Detachment  of,  509 

,  Diseases  of,  596 

,  Glioma  of,  6aj 

Retinitis,  598 

pigmentosa,  599 

.  Varieties  of,  59S 

Rhinitis,  510 
Rbinolith,  510 

Sacro-coccygeal  joint.  Injuries  of, 
469 

tumours,  431 

Sacrum,  Fracture  of,  62 
Salivaiy  glan«1s,  Aflections  of,  487 
Sarcoma  of  bone,  140,  141 
Saj-re's  jacket,  4U 
Scalp,  Abscess  of,  366 

,  Cellulitis  of,  365,  388 

,  Contusions  of,  381 

,  Erysipelas  of,  365 

,  Hcematoma  of,  366,  382 

,  Inflammation  of,  388 

,  Injuries  of,  380 

,  Tumours  of,  366 

,  Wounds  of,  384 

Scapula,  Fracture  of,  38 
Sclerosi-*,  lol,  104,  110 
Sclerotic,  Diseases  of,  578 
Scoliosis,  327 
Scrofula  of  bone,  131 


620 


Manual  of  Surgery. 


Scrofulous  diseases  of  joints,  242 

Sebaceous  cysls,  367 

Semilunar  cartilage,  Dislocation 
of,  200,  256 

Sequestrotomy,  126 

Sequestrum,  124 

Shoulder  joint.  Disease  of,  271 

Skull,  Diseases  of,  372 

,  Fracture  of,  893 

of  base  of,  393 

of,  Varieties  of,  395 

,  Hypertrophy  of,  376 

,  Injiu:ies  of,  393 

,  Osteitis  of,  391 

,  Tumours  of,  373 

Spina  bifida,  427 

veutosa,  109 

Spinal  coid,  Concussion  of,  470 

,  Inflammation  of,  454 

,  Injiiries  to,  460 

Spine,  Caries  of,  432,  445. 

,  Ciurvatiures  of,  327,  335,  336 

,  Disease  of  cervical,  442 

,  Diseases  of,  427 

,  Dislocation  of,  457,  4G7,  469 

,  Fracture  of,  457,  467,  469 

,  Injuries  of,  447 

,  Pott's  disease  of,  432,  445 

,  Eailway,  452,  471 

,  Sprains  of,  4i9 

Spondylitis  deformans,  445 

Sprain-fractiu'es,  150 

Sprains,  150 

Staphyloma,  Posterior,  602 

Strabismus,  612 

Strumous  node,  133 

Stye,  541 

Subastragaloid  dislocation,  207 

Supracondyloid  fracture  of  hume- 
rus, 47 

Surgical  neck  of  humerus.  Frac- 
tures of,  42 

Sutures,  Separation  of,  400 

Symblephxiron,  559 

Sympathetic  alfections  of  eye,  581 

Synovitis,  Acute,  210 

,  Chronic,  211 

,  GonorrhcEal,  229 

,  Gouty,  219 

in  specific  fevers,  229,  231 

,  Puerperal,  229 

,  Pyaemic,  227 


SjTiovitis,  Rheumatic,  215,  217 

,  Scrofulous,  242 

,  Syphilitic,  224 

Sypbilis  of  joints,  224 

Syphilitic  disease  of  bone,  134, 136 

Talipes,  338 

calcaneus,  351 

cavus,  355 

equinus,  342 

valgus,  352 

varus,  S45 

Tarsotomy,  341 
Tarsus,  Fracture  of,  92 
Tt  etb  in  syphilis,  137 
Tendons,  Dislocation  of,  312 

,  Injuries  of,  311 

Teno-syuovitis,  313 
Tenotomy,  34J 
Thumb,  Dislocation  of,  185 
Thyroid  body,  Affections  of,  490 
Tibia  and  fibula,  Fracture  of,  85 

Fracture  of,  85 

Tinnitus  auriutn,  538 
Toe,  Deformities  of,  361 
Torticollis,  324 

Trachea,  Foreign  bodies  in,  496, 
498 

,  Wounds  of,  474 

Tracheotomy,  504 
Ti'achoma,  554 
Trephining,  421 
Trichiasis,  542 
Tubercle  in  bone,  131 
Tumours  of  bone,  140,  145 
of  joints,  260 

Ulna,  Dislocation  of,  180,  182 
— — ,  Fracture  of,  57 

Vision,  Errors  of,  609 
Vitreous,  Diseases  of,  604 

,  Foreign  bodies  in,  607 

,  Opacities  in,  604 

Whitlow,  314 
Wounds  of  joints,  152 
Wrist,  Disease  of,  275 

,  Dislocation  of,  184 

Wry  neck,  324 

Xerophthalmos,  558 


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RD31T72  1892C.1v.  2 

A  manual  of  surqef 


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